legal and ethical issues in mental health nursing essay

Mental Health Nursing Practice and Ethical Issues Essay

Introduction, the scenario of ethical dilemma case, scenario’s ethical conflicts, possible action plan based on ethical theories and principles.

For nurses, their job is hard daily work requiring profound knowledge, skills, and dedication. The profession demands them to be sustainable and responsible, meet the requirements, and comply with the main work principles. With nurses, patients most often communicate, ask and answer, talk and listen. Hospitals, in particular those dealing with patients with mental illness, are considerably challenging places of work. Employees daily see human suffering, own limited capabilities, and face severe ethical dilemmas. Solving ethical problems also requires precise knowledge and professionalism, the ability to make the best decision in critical situations.

Psychiatry differs significantly from other areas of medicine, including in ethics. The field is gradually expanding as, in addition to clearly defined diseases, personnel also should deal with more hidden disorders. At the same time, society is still not tolerant enough towards patients with mental illness and has prejudices. Such an image affects the desire to seek professional help, provokes a pessimistic view on treatment, and makes patients even more vulnerable. Moreover, this image can affect the social and professional life of the patient. For this reason, ethical treatment has a critical significance in relations between patients and medical staff.

The most effective medical and psychiatric care is provided in a hospital. In their practical activities, doctors and nurses of the department should be guided by the principles of medical ethics. For example, among the main requirements that stand out: the actions aimed at the benefit of patients, respecting their interests, and medical confidentiality. Mentally ill people do not always realize that their condition is dangerous – for themselves or surrounding people. Therefore, the situation of providing them help in the psychiatric hospital is perceived as violent and often provokes resistance. In the hospital, such people often refuse treatment, the need to observe the regime, and taking drugs. Doctors and staff have to resort to coercion, which, however, should not contradict the humane approach to the patient.

The scenario presented and studied below is hypothetical, and similarities with real people are coincidental. However, considered ethical dilemmas might arise in actual nursing practice. The purpose of the presented case and analysis is to evaluate the ethical aspects of providing care to a patient in a psychiatric ward. Another objective of the paper is to provide recommendations for treatment in accordance with the moral and ethical principles of the profession of a mental health nurse.

Michael is a 28-year-old man who cannot continue his career as an athlete due to an injury – he lost his leg. The sport was the basis of his life, and the man devoted all his time and efforts to it. Besides sports, Michael had few activities and hobbies, and he sought to build a career only in this area. The incident during vacation, which led to an injury, happened two years and since then, Michael’s psychological condition has been deteriorating.

He is divorced, has no children, and does not maintain relations with his parents. At first, the man sought to survive only the loss of his leg, but then he felt confused and uncertain about what his life was worth. He is also always tired, annoyed and speaks of feeling ill. Since the primary basis in his life is destroyed, he does not see the goal before himself, feels the meaninglessness and pity of his situation. Due to lost opportunities and not seeing prospects for the future, Michael is experiencing depression.

Hospitalized after a suicide attempt, Michael does not want to take medication but still does, obeying the rules. Disability as a result of the trauma and hospitalization significantly depresses the man, and he sees no point in taking drugs. Besides resisting medication sometimes, Michael is apathetic to staying in the hospital, prefers being private, and does not participate in discussions. Although the man’s time in the hospital is relatively short, there is no sign of improvement, and even vice versa – he is very devastated.

Concerned about Michael’s condition, nurses seek extraordinary control – they check whether there are any things that can be used for harm. They also carefully monitor medication use and consider the option of adding medication to food fraudulently if Michael will refuse to take them. However, deception threatens to worsen relations with the patient and can provoke his resistance. Moreover, questions arise about how acceptable such actions are and whether they violate patient autonomy. This concept implies people’s freedom to make crucial decisions that concern them personally, including their treatment. However, the disease can disrupt the ability to think reasonably and push for wrong choices. At the time of arriving in the hospital, nurses can note the following characteristics of the patient:

• Risk of harm associated with feelings of inferiority and hopelessness.
• Ineffective coping with trauma and its consequences – disability.
• Grief related to irretrievable lifestyle changes and lost life values.
• Social exclusion related to family separation and non-communication.

Thus, Michael suffers from depression and requires treatment so that no new incidents occur. This condition is quite common and is often not taken with sufficient severity. People suffering from depression feel sad, hopeless, insecure, and experience many other negative emotions (“Depression,” 2020). Failing to provide Michael with timely care could lead to a new suicide attempt. However, with proper treatment, he has a chance to find and discover new opportunities for himself.

Nurses that usually communicate with patients much closer and more than doctors face the suffering and pain of their wards directly. At the same time, they have a crucial role in supporting the ethical treatment and preservation of human rights (Ventura et al., 2020). Ethical conflicts may arise when nurses are unsure which direction of the patient support to choose. While staff behavior should be consistent with the benefit of their patients, there may be different views on it. For example, actions will benefit in the future but violate patient autonomy. Moreover, sometimes nurses may disagree with the chosen course of action concerning a person, and, as a result, moral pressure arises (Ventura et al., 2020). For these reasons, stress tolerance and the ability to make decisions based on accepted ethical principles are essential.

Nurses exhibit paternalism in the described scenario, which is common in the field. This concept reflects the practice where people with specific power can restrict those who are subordinate or dependent on them (Ventura et al., 2020). Patients are obliged to respect the work of medical personnel and obey their instructions as they act in the interests of their wards (“When hospitalization is needed,” 2020). At the same time, nurses can limit autonomy while the patient is under supervision, hoping that he will be able to manage his freedom independently, adequately, and for good in the future.

One solution to the described situation is the option where Michael’s incompetence in solving issues of self-care and his health will be proved. The state of depression in which the man is in and the tendency to suicide indicate the possibility that he can choose a decision which he would not make without depression. Depression is characterized by impaired information processing and perceiving the world in a pessimistic view (Baruth & Lapid, 2017; LeMoult & Gotlib, 2019). Owen et al. (2018) study proves that people with depression have a broken vision of reality and projecting themselves into the future, which is critical for self-determination and decision-making. Proven incompetence solves the conflict of autonomy of the patient because he cannot act in the name of his well-being.

Incompetence in decision-making must be established officially, and a guardian must be appointed. Michael, as an adult, is considered competent if the opposite is not proven (Australian Law Reform Commission, 2010). The recognition process may take a long time, and since Michael currently has no relatives whom he would fully trust, there will also be problems in finding a guardian. A lengthy process will take time, which could be spent on treatment and not promote patient trust in the staff. Nevertheless, it is critical to consider Michael’s autonomy, as otherwise, nurses may face severe moral and legal complications.

If Michael is recognized as competent in decision-making, the conflict about how much his autonomy relates to his well-being remains open. Several additional factors are essential and influential for his case. His state of depression is reversible since, with proper treatment, he may see new prospects. Michael’s disability, although it may limit his freedom, still leaves him with many opportunities in life. In addition, the intervention of nurses is not violent, does not cause severe physical inconvenience, and is aimed at the patient’s benefit.

A potential violation of a patient’s autonomy may also contradict his right to dignity. Although some researchers argue that the concepts of dignity and autonomy are interchangeable, their differences are still crucial for ethical decision-making in healthcare (Simões & Sapeta, 2019). The researchers also note the fact that despite the importance of understanding dignity in medicine, no single definition has yet been inferred for it (Simões & Sapeta, 2019). Dignity refers to the practice when the individual is treated respectfully and honorably – patients whose dignity the staff respects feel they are worth as people and deserve a good attitude. Respect for human dignity is critical for treatment, as it is the basis for patient-centered care. In Michael’s case, excessive surveillance, he may perceive as disrespectful for him and as a violation of personal boundaries. However, the concept of dignity also includes self-respect, which in this case, is disrupted. Michael may temporarily not adequately perceive himself and his desires due to a depressed condition.

This case can also be considered from the point of view of such ethical principles, which should guide representatives of medical personnel in their actions as veracity and fidelity. They suggest that nurses should be honest with patients and loyal to them (Casale, 2017). The fact that nurses are considering the cheating option indicates a violation of integrity. At the same time, their actions, in their opinion, are probably aimed at improving the patient’s life. For this reason, the issue of fidelity is intertwined with the conflict of autonomy. Nurses are faithful to Michael’s interests because they think about his possible future – this is a manifestation of loyalty. At the same time, their actions against the patient’s will violate the trust which can be achieved between them.

As demonstrated in the previous section, the present case is characterized by several ethical conflicts. Nurses’ actions should be based on ethical concepts and theories. According to Casale (2017), utilitarianism involves achieving the common good – happiness for more people by any means. It may seem that this approach suggests the possibility of cheating or declaring Michael incompetent. However, in this case, the nurses will be under moral pressure. Kantianism is the opposite direction, which puts forward the path to achieving a specific goal and not the goal itself. As part of this approach, the principles of autonomy, beneficence, nonmaleficence, and similar are considered (Casale, 2017). Based on both of these approaches, nurses should choose more ethical actions instead of deception – they will bring more good and be more consistent with professional duties.

Michael’s autonomy and dignity are also critical for his recovery and must be respected. Trusting relationships with nurses can contribute to his sooner healing. Ignoring independence and dignity will also violate the principles of beneficence and nonmaleficence. Impaired by disability, Michael’s self-esteem may suffer even more if he learns about deception and disrespect by staff. Moreover, as indicated earlier, his possible incompetence in decision-making must be formally proven and may have destructive consequences for self-perception. Fraud by nurses is also excluded so that the principles of honesty and fidelity are respected. Based on all the arguments presented, nurses cannot give Michael drugs fraudulently, and it is necessary to focus on treatment – the effects of drugs and his moral support.

Thus, the proposed scenario of patient Michael suffering from depression and suicidal ideation raises several ethical conflicts. Nurses concerned about the condition of the man show excessive paternalism and consider deceiving the patient for his benefit. For this reason, the most crucial issue in the case is the question of the balance of the patient’s autonomy and well-being in the circumstances of a depressive condition. Staff fraud also involves a violation of the principles of fidelity and veracity. Nurses have the task of acting for Michael’s recovery while respecting the necessary ethical principles.

Based on existing ethical theories and principles, patient autonomy is preferred in this case. For his part, Michael as a patient, must respect the rules established in the hospital. Nurses must treat him with dignity and respect to provide patient-centered care. This approach is necessary for the patient as it will contribute to improving the emotional state. In the case, if the deterioration of the condition noticed by nurses continues to be observed, Michael’s doctors should consider the option of changing drugs. Thus, in this case, nurses should focus on a softer and more ethical approach.

Nurses’ actions should be based on attention and the ability to listen to the patient. Understanding a person in a depressed state, his thoughts, often not coinciding with reality and reacting correctly, is a very challenging task. For instance, it is especially critical to avoid condescension, neglect, and pity in the conversation in Michael’s case. Therefore, mental health care has high requirements for nurse professionalism and the development of patient communication skills.

Australian Law Reform Commission. (2010). Adults with a temporary or permanent incapacity . Web.

Baruth, J. M., & Lapid, M. I. (2017). I nfluence of psychiatric symptoms on decisional capacity in treatment refusal . AMA Journal of Ethics , 19 (5), 416-425. Web.

Casale, K. R. (2017). Ethical and legal principles . Nurse Key. Web.

Depression . (2020). Health Direct. Web.

LeMoult, J., & Gotlib, I. H. (2019). Depression: A cognitive perspective . Clinical Psychology Review , 69 , 51-66. Web.

Owen, G. S., Martin, W., & Gergel, T. (2018). Misevaluating the future: Affective disorder and decision-making capacity for treatment–a temporal understanding. Psychopathology , 51 (6), 371-379. Web.

Simões, Â., & Sapeta, P. (2019). The concept of dignity in nursing care: A theoretical analysis of the ethics of care. Revista Bioetica , 27 (2), 244-252. Web.

Ventura, C. A. A., Austin, W., Carrara, B. S., & de Brito, E. S. (2020). Nursing care in mental health: Human rights and ethical issues . Nursing Ethics. Web.

When hospitalization is needed for depression . (2020). WebMed. Web.

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Nursing care in mental health: Human rights and ethical issues

Affiliations.

• 1 67816University of São Paulo at Ribeirão Preto College of Nursing, Brazil.
• 2 3158University of Alberta, Canada.
• PMID: 33111635
• DOI: 10.1177/0969733020952102

People with mental illness are subjected to stigma and discrimination and constantly face restrictions in the exercise of their political, civil and social rights. Considering this scenario, mental health, ethics and human rights are key approaches to advance the well-being of persons with mental illnesses. The study was conducted to review the scope of the empirical literature available to answer the research question: What evidence is available regarding human rights and ethical issues regarding nursing care to persons with mental illnesses? A scoping review methodology guided by Arksey and O'Malley was used. Studies were identified by conducting electronic searches on CINAHL, PubMed, SCOPUS and Hein databases. Of 312 citations, 26 articles matched the inclusion criteria. The central theme which emerged from the literature was "Ethics and Human Rights Boundaries to Mental Health Nursing practice". Mental health nurses play a key and valuable role in ensuring that their interventions are based on ethical and human rights principles. Mental health nurses seem to have difficulty engaging with the ethical issues in mental health, and generally are dealing with acts of paternalism and with the common justification for those acts. It is important to open a debate regarding possible solutions for this ethical dilemma, with the purpose to enable nurses to function in a way that is morally acceptable to the profession, patients and members of the public. This review may serve as an instrument for healthcare professionals, especially nurses, to reflect about how to fulfil their ethical responsibilities towards persons with mental illnesses, protecting them from discrimination and safeguarding their human rights, respecting their autonomy, and as a value, keeping the individual at the centre of ethical discourse.

Keywords: Ethics; human rights; nursing care; persons with mental illness.

Publication types

• Human Rights
• Mental Health
• Nursing Care*
• Paternalism
• Psychiatric Nursing*

• Open access
• Published: 25 January 2023

The psychiatric mental health nurse’s ethical considerations regarding the use of coercive measures – a qualitative interview study

• Charlotta Manderius   ORCID: orcid.org/0000-0002-1232-3558 1 ,
• Kristofer Clintståhl   ORCID: orcid.org/0000-0003-0829-8019 2 ,
• Karin Sjöström   ORCID: orcid.org/0000-0002-7466-5086 3 &
• Karin Örmon   ORCID: orcid.org/0000-0002-0228-1358 3 , 4  

BMC Nursing volume  22 , Article number:  23 ( 2023 ) Cite this article

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In psychiatric inpatient care, situations arise where it may be necessary to use coercive measures and thereby restrict individual autonomy. The ethical principles of healthcare, i.e., respect for autonomy, beneficence, nonmaleficence, and justice, are recognized as central aspects in healthcare practice, and nurses must be clear about which ethical theories and principles to prioritize and what values are needed for a thorough ethical consideration. The aim of this study is to shed light on psychiatric mental health nurses’ ethical considerations and on the factors influencing them when performing coercive measures.

This qualitative interview study included twelve psychiatric mental health nurses with experience from psychiatric inpatient care. A content analysis was made. The interviews were audio recorded and transcribed verbatim, and categories were formulated.

The study revealed a duality that created two categories: Ethical considerations that promote the patient’s autonomy and health and Obstacles to ethical considerations . Based on this duality, ethical considerations were made when performing coercive measures to alleviate suffering and promote health. The result shows a high level of ethical awareness in clinical work. However, a request emerged for more theoretical knowledge about ethical concepts that could be implemented among the staff.

The psychiatric mental health nurses in this study strive to do what is best for the patient, to respect the patient’s autonomy as a guiding principle in all ethical considerations, and to avoid coercive measures. An organizational ethical awareness could increase the understanding of the difficult ethical considerations that nurses face with regard to minimizing the use of coercive measures in the long run.

Peer Review reports

According to the International Council of Nurses (ICN) [ 1 ], the nurse has an ethical responsibility and must be aware of the power that lies in the practice of the profession. Furthermore, all care has basic humanistic values, according to the Swedish Health and Medical Service Act [ 2 ], and this means that people who are cared for according to the Swedish Compulsory Psychiatric Care Act [ 3 ] are entitled to the greatest possible autonomy.

Sweden’s municipalities and regions have since 2008 conducted a national improvement work where the goal is to reduce the need for coercive measures in psychiatry, as treating someone against their will and using coercion involves several ethical dilemmas [ 4 ]. Furthermore, the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) [ 4 ] mentions that preventive measures, other than coercive ones, can to some extent have an effect. Persons cared for under the Swedish Compulsory Psychiatric Care Act [ 3 ] are in a vulnerable situation, where the nurse has the important task of protecting the patient from injury as well as providing good care [ 5 ].

In a clinical care setting, good care is characterized as individualized, patient focused and related to need; it is provided humanely, through the presence of a caring relationship and by staff who demonstrate involvement, commitment, and concern [ 6 ]. It differs somewhat from beneficence, as proposed by Beauchamp and Childress [ 7 ], which refers to acts of kindness, charity, and altruism, where a beneficent person does more than the bare minimum.

With this in mind, it can be problematic for the nurses to engage in ethical considerations that are in favor of or against a coercive measure, according to Olofsson et al. [ 8 ]. Refraining from a coercive measure can be just as devastating as carrying it out in certain situations. Thus, failure to carry out a coercive measure may go against doing the right thing, but on the other hand, the coercive measure may infringe the patient’s integrity, autonomy, and dignity.

In Sweden, the conditions for applying the Compulsory Psychiatric Care Act [ 3 ] are as follows: the person suffers from a serious mental disorder; the person has an indispensable need for psychiatric care, which cannot be met in any other way than through qualified psychiatric round-the-clock care; the person opposes care or, because of their mental condition, lacks the ability to take a stand on the issue. Compulsory care may not be provided if the patient’s mental disorder consists only of an intellectual disability. Something that must also be considered is whether the patient, because of their mental disorder, is dangerous to another’s personal safety or physical or mental health. Medical restraints, like fixation, forced medical treatment, such as injections of medication and seclusions, are some coercive measures that are relevant to use during the application of the Compulsory Psychiatric Care Act [ 3 ]. These three coercive measures may create ethically difficult situations for the nurse due to the risks that may arise in connection with the measures [ 9 ].

There are also, according to Szmukler and Appelbaum, several kinds of informal coercion or treatment pressures, such as persuasion, interpersonal leverage, inducements, and threats before the use of compulsory treatment [ 10 ], that may be ethically challenging for nurses.

Coercive measures are not only integrity challenging but are also related to serious risks for mentally ill patients. Trauma similar to posttraumatic stress disorder has been reported [ 11 ], as well as suicidal attempts and self-damage [ 12 ]. Other complications are cardiac arrest and pulmonary thrombo-embolism, which could be fatal, especially in connection to longer periods of restraint [ 13 , 14 ]. Moreover, according to a Cochrane review, there is no evidence that coercive care, such as seclusion and restraint, benefits mental health [ 15 ].

Coercive measures may also create ethically difficult situations for the nurse due to the risks that may arise in connection with the measures [ 1 ]. There is, for instance, a risk that patients will not be able to communicate their wishes [ 16 ], which may lead to violation of the patient’s dignity [ 17 ] and, in turn, to a deteriorating treatment alliance [ 5 ]. Ethical dilemmas may also occur when there are different perceptions of what is right and wrong in treatment, as everyone has their own perceptions of and values regarding what is good and bad [ 18 , 19 ]. According to Andersson et al. [ 18 ], coercive measures, such as mechanical restraint, are an established part of care where restraints are an act of good will and considered necessary to protect the patients from injuring themselves, although the nurse desires to provide care and relieve suffering. It is important to keep in mind that all care must be provided with respect for the equal value of people and for the dignity of the individual, according to the Health and Medical Services Act [ 2 ].

The psychiatric mental health nurse must work to maintain respect for the person’s dignity, integrity, and self-determination; give the individual the opportunity to experience trust, meaning, and hope; work to support other employees in achieving a higher ethical awareness; and be aware of when respect for fundamental values is threatened [ 1 ]. Olofsson et al. [ 8 ] have highlighted the importance of protecting the patient’s health from employees’ wrongdoing. By reflecting on and being responsible for ethics in the workplace, the nurses can challenge their own ethical competence [ 1 ] and have a responsibility to give life to the ethical discussions to strengthen the quality of nursing by developing an ethical compass among the staff.

Being able to reflect ethically, having ethical knowledge, acting ethically, behaving ethically, and engaging in ethical considerations, are the basis for all nursing care. Previous studies have described the nurse’s experience of performing coercive measures [ 5 , 8 , 18 , 20 ]. However, few studies have explained what ethical considerations nurses engage in when performing coercive measures [ 21 , 22 ]. Beauchamp and Childress [ 7 ] have presented a framework for the ethical assessment of alternative courses of action in healthcare, where the following four principles are particularly central: respecting patient autonomy, acting on the principle of beneficence, being aware of the principle of no harm, and attending to the principle of justice. These four principles may be a starting point for ethical considerations. Other principles, such as trust, care, and solidarity, are of no less value, but the nurse must decide what promotes health and relieves suffering. According to Hem et al. [ 21 ], there is, at present, a growing awareness of ethical challenges. Hence, modern healthcare values the patient’s autonomy higher than in the past. It is statutory that care should be designed and implemented in consultation with the patient as far as possible [ 2 ]. One of the challenges for the nurse is to balance the patient’s autonomy with the safety of others and at the same time let the patient participate without coercion [ 21 ]. The authors of this study believe that nurses must, through careful ethical consideration, clarify for themselves which ethical theories and principles are of priority and what values are achieved in each specific situation. In psychiatric practice, the psychiatric mental health nurse faces ethical considerations daily about what should be done and what is considered the right thing to do for the patient, which in turn may create conflicts of conscience. In a study by Jensen and Lidell [ 23 ], nurses believed that their own conscience played a major role in ethical considerations and that it was important to stand up for their own ethical values and listen to their conscience. Several different factors, such as previous experiences, interpersonal and collegial relationships, emotions, laws, rules, and constellations of power, influence the psychiatric mental health nurse’s ethical considerations. In particular, it is ethically difficult when the nurse has to implement coercive measures without being involved in the decision [ 5 , 8 ]. Even so, according to the ICN [ 1 ], the psychiatric mental health nurse has a responsibility to lead the ethical discussion in order to strengthen the quality of nursing. Therefore, the aim of this study is to further explore this research area with the purpose of examining the psychiatric mental health nurse’s ethical considerations and investigating what factors are of importance for ethical considerations when using coercive measures.

Design, sample, and setting

The study was designed as a qualitative interview study. The aim was a selection of participants that would lead to an increased understanding of variations within the subject to be studied. The inclusion criteria were psychiatric mental health nurses, with a one-year master exam, who worked or had recently worked in inpatient psychiatric care and participated in and ethically reflected on coercive measures. The study was conducted in the southern part of Sweden. The recruitment of participants was done in 2021, during the month of February. Men and women of different ages and with experience from different psychiatric clinics, were included, in order to get the greatest possible variation in the answers (Table  1 ).

Data collection

Semi-structured [ 24 ] interview questions were developed through conversations and reflections among the authors. The questions aimed to capture the psychiatric mental health nurse’s ethical considerations when performing coercive measures, without intent to study any particular coercive measures. A total of twelve psychiatric mental health nurses were interviewed. The authors chose to conduct a preparatory interview to investigate whether the questions asked were relevant and clear for the purpose of the study. During the preparatory interview, it emerged that the participant would have preferred to see the questions in advance as the subject required reflection. Following the preparatory interview, the other participants therefore received sample questions together with information about the purpose of the study and a consent form. After the preparatory interview, the questions were slightly adjusted for clarification without altering their essence. Hence, the preparatory interview was included in the results. Nine of the participants chose to be interviewed at their workplace and three to be interviewed through the digital conference Zoom. The duration of the interviews was between 30 and 60 minutes, and they were recorded and transcribed verbatim.

Data analysis

Collected data were analyzed by the authors, according to Burnard [ 25 ], who describes fourteen steps to perform a manifest qualitative content analysis. Twelve of the fourteen steps were used in the analysis. The category check by respondents was excluded as well as comparing the collected data with previous research. The transcript was read repeatedly in order to delve into the material and describe all aspects of the content. An open coding was done by giving each emerging topic a heading, and the headings were merged into higher-order headings. The procedure was repeated to further shape the central parts of the interview. The transcripts were re-examined and compared with the categories obtained so that the latter covered all parts of the content of the transcripts. Data that corresponded to the purpose of the study were coded into different sections. Each coded section of the interviews was then cut out of the transcript and all parts of each code were collected. The cut-out sections were pasted into a separate document with appropriate headings and subheadings. The findings were collected under each respective heading and category. In order to ensure that the findings were not taken out of context, both a complete transcript of the interview and the original audio recording were always available. A compilation of the results was started by processing each section separately, and representative quotations were selected. The authors remained open to the interview material throughout the writing process (see Table  2 , for the process of analysis).

Trustworthiness

The authors aimed for trustworthiness in accordance with standard criteria for qualitative research [ 26 ]. The thorough description of design and method, as well as the description of setting and participants and the choice of quotations to strengthen the result, enriched the credibility of the results. The authors discussed the material throughout the progression of the analysis, which also enhanced the credibility. Two of the authors conducted the interviews, as well as using an interview guide, which was beneficial for achieving dependability.

Three of the authors are psychiatric mental health nurses and one of the authors is a psychiatrist and psychotherapist. All authors are experienced in psychiatric in- and outpatient care and in performing coercive measures. The fact that the authors have experiences from a variety of psychiatric care contexts has been valuable throughout the methodological process.

Ethical research considerations

This study was based on four ethical research principles: the information requirement, the consent requirement, the confidentiality requirement, and the utilization requirement [ 27 ]. Prior to the interview, the participants received written information that the interviews would be recorded, that the material would be de-identified, that it was voluntary to participate, and that they could withdraw at any time . Written informed consent was obtained from all participants prior to the interview. The study was approved by the university and the psychiatric department of the hospital. Approval from an Ethics Committee was not required for this type of study as it could not be traced to individual participants, did not process sensitive personal data according to the General Data Protection Regulation (GDPR) [ 28 ], and did not affect the participants physically or mentally [ 29 ].

This study found a duality between the psychiatric mental health nurses’ ethical considerations with regard to coercive measures and the obstacles to those considerations. This finding led to the creation of two categories and five headings, in accordance with Burnard [ 25 ] (see Table  3 ).

It emerged that the psychiatric mental health nurses in this study saw coercive measures as major threats to the patient’s autonomy. At the same time, they all considered coercive measures to be necessary on certain occasions, in order to alleviate suffering and promote patient health. It also emerged that ethical considerations were hindered by professional loneliness and a lack of understanding on the part of other staff. It was in this predicament that that the psychiatric mental health nurses engaged in ethical considerations when performing coercive measures.

“We are not allowed to exercise power over the patient and coercive measures are the last measure we should resort to.” (Participant 6).

Ethical considerations promoting patient autonomy and health

This category describes ethical considerations made by the psychiatric mental health nurses in order to preserve the patient’s autonomy in each situation where coercive measures were considered. The ethical considerations, which were also based on personal ethical principles, were made for the benefit of the patient, in order to prevent coercive measures as far as possible.

Ethical considerations to reduce suffering for the benefit of the patient

A number of ethical considerations were made with the patient’s best interests in mind. There was a desire to preserve the patient’s autonomy and dignity, by involving the patient as much as possible in the decisions, and to persuade the patient to receive help on a voluntary basis. The participants were clearly aware that the patient’s condition could be improved in both the short and the long run through coercive measures. As the patient’s suffering was reduced, ethical considerations were facilitated.

“Coercive measures are used for the benefit of the patient and to break various difficult conditions. … It’s hard, but the patients may thank us afterwards because it’s about alleviating suffering.” (Participant 3).

The participants also believed that it was in the patients’ best interests to prevent them from forcibly causing harm to fellow patients and themselves, which later could lead to an increase in suffering. The importance of nursing knowledge and of measures being based on the ethical principle of beneficence, was expressed by all participants. Furthermore, the participants agreed on those ethical considerations being situational, always based on the patients’ current mood, and requiring attention to whether it was necessary or not to carry out a coercive measure. The preservation of dignity was seen as an important principle in nursing.

“Preserve the patient’s dignity. That is also a consideration. Not only here and now but in the long term.” (Participant 12).

In their ethical considerations, participants thought a lot about the patient’s vulnerability. Not exposing the patient’s body more than necessary when giving forced injections, or only allowing female staff to be present in a coercive procedure if the patient had previously been mistreated by men, were examples of situations where the patient’s vulnerability was considered. The participants also stated that seclusion could sometimes be justified in order to preserve patient dignity. The ethical consideration in that situation was about protecting both the patient in question and other patients from embarrassment or shameful suffering. All participants emphasized that coercive measures should never be a punishment and that non-urgent coercive measures called for careful planning in order to maintain the patient’s autonomy and dignity, and at the same time minimize suffering. The participants stated that forced injections could be traumatic, but by informing and involving the patient, the trauma would be as minimal as possible. The patients’ participation could be promoted by allowing them to choose the method of administration of the drug, the place of administration, the position, on which side the injection would be given, who would perform the procedure, how many would be in the room, and who would remain with the patient afterwards. It also emerged that participation could be increased by giving patients the opportunity to tell how they felt afterwards. The ethical consideration was about promoting the patient’s self-determination through participation in order to minimize any feeling of abuse of autonomy.

“The important thing is to make the patient understand what we’re doing, for then the patient may experience the coercive measure as less of a violation, I believe.” (Participant 6).

None of the participants considered it unproblematic to carry out coercive measures, but those performed were considered ethically defensible as the patient’s wellbeing was in focus. The ethical considerations revolved around having to oppose the patient’s autonomy while promoting the patient’s health and, hence, reducing suffering in the end.

Ethical considerations based on personal ethical principles

The nurses’ own ethical point of view was important for their ethical considerations and the differences in their ethical reasoning that emerged were related to experience and self-esteem. Many participants stated that they maintained internal ethical monologues that concerned their conscience as well as loyalty and solidarity towards patients and staff.

“We nurses must be more assertive. Talk and listen to the patient. Not prescribe a coercive measure and then listen, but listen and then prescribe, if it so happens that it’s necessary.” (Participant 6).

According to the participants, it felt more right to act on their own conscience than on the mere duty to implement a coercive measure that they felt could not be justified, especially if the purpose of the coercive measure did not correspond to a fair and humane treatment. The majority expressed that experience contributed to both thoughtfulness and more carefully thought-out and planned ethical considerations. Some expressed that earlier in their professional careers, when less experienced, they valued duty higher than their own ethical convictions, in, for example, enforcing a doctor’s compulsory prescriptions even though the participants did not consider it fair or in the patient’s best interests. When less experienced, the participants relied more on the skills of others than on their own skills.

“The ethical aspect has become more difficult because you sort of think more about the situation today than you did earlier. Before, it was more a matter of following the prescription given by the doctor, it was my duty.” (Participant 8).

Some coercive measures, such as involuntary injections, were more difficult for the participants to handle. The ethical considerations were along the lines that it hurt for a short while but was beneficial for the patient in the long run. One of the participants stated that force-feeding was an example of the patient’s health being promoted in the long term, despite increased patient anxiety both during and after the coercive measure. Another difficult ethical dilemma arose when patients suffered from cognitive impairment or dementia and the nurses were not able to communicate with the patient or convey the purpose of the coercive measure. According to several participants, it was also ethically challenging when patients perceived that they did not have a choice.

“ The thing about ethical considerations, how to draw the line for a coercive measure. […] my conviction [was] that I should do everything I could to make the patient take the pill in order to avoid it [the injection] and not just do it automatically. ” (Participant 1).

Even if the patient agreed to receive a forced medical injection, the participants sometimes perceived that the patient’s autonomy was violated, which was seen as a dilemma. It emerged, however, that for the participants, treatment pressures felt better for their ethical conscience than if the patient risked being subjected to stronger coercive measures, such as mechanical restraint, to obtain the prescribed injection. When it was necessary to ask for assistance from other departments for a planned coercive measure, the nurses felt that the increased number of staff could lead to a feeling of inferiority in the patient, a feeling that might subsequently be consolidated. In such cases, preventing the exercise of power and the exploitation of the patient’s vulnerability and weakness was uppermost in the participant’s ethical considerations. Informal coercion was another problematic ethical issue, however, and it was also considered problematic to document it in a proper way.

Ethical considerations create relationships and trust

The participants were aware that the relationship with the patient sometimes varied depending on the medical condition. Many participants emphasized that preventive measures were crucial in creating trust and a relationship with the patient, in order to avoid having to apply coercive measures. The foundation for nursing interventions was considered to be accurate treatment based on good communication.

“All these things that we do are very much built on relations. The patient should know that I do all this because the patient needs this care and not because I want to use my power.” (Participant 7).

According to most participants, there was a possibility that the relationship between patient and nurse would be influenced in the execution of coercive measures, which in turn affected the ethical considerations. The ethical considerations revolved around the fact that the relationship risked being temporarily damaged at the same time as the coercive measure improved the patient’s mood. The majority of the participants reflected on whether the person who had the best relationship with the patient was the one who should carry out the coercive measure or not. In most cases, such decisions were made based on the situation and the existing relationship. It was suggested that the patient could be involved by being able to choose who would perform a coercive measure, which would avoid damaging an existing relationship.

“Give the patient a choice, involve the patient.” (Participant 9).

The majority of the participants stated that it was particularly difficult to maintain a relationship with patients who lacked insight into their mental illness. The relationship was often affected by the current state of the patient’s illness, such as manic relapses, psychotic breakthroughs, and paranoia. Dementia diseases, cognitive impairment, language confusion, and language barriers were perceived by the participants as an obstacle to relationship building. Not being able to communicate was difficult, which, in turn, made it difficult to create trust and thus build a relationship. The relationship between patient and nurse was important in the preventive work to avoid coercive measures.

“ [The patient] was completely convinced that this situation would lead to their death. This was difficult to meet … it was both the language barrier and this conviction that the patient had that we were actually in a concentration camp. ” (Participant 1).

Many of the participants expressed that it felt difficult not to be able to convey the purpose of the coercive measure to the patient. Lack of communication could create a feeling of abuse and thus increase the patient’s suffering. The ethical considerations in these situations were particularly difficult for the psychiatric mental health nurses.

Obstacles to ethical considerations

In this category, it emerged that obstructive factors affected the participants while they were making ethical considerations, thereby hindering the preservation of the patient’s autonomy. The obstructive factors in question were loneliness in the profession and a lack of understanding of the ethical dilemma.

Loneliness in the profession

It emerged during the interviews that the participants felt that a high level of ethical awareness was required in order to provide psychiatric care. It also emerged that the participants felt that there were shortcomings in the understanding of the psychiatric mental health nurses’ ethical considerations, which tended to complicate the nursing work in connection to coercive measures. The participants stated that they sometimes experienced pressure for coercive measures from other categories of staff and that this contributed to a feeling of loneliness in their ethical considerations.

“ If you don’t have [ethical] knowledge, then things can go so wrong when coercive measures are applied. They mean well but do the wrong thing. It’s often a matter of lacking knowledge. So, education is in fact the foundation for everything. ” (Participant 8).

The majority of the participants requested more ethical knowledge, which they believed would enable a better response and a greater understanding of the patient’s current illness. Several participants claimed that they had received pressure from nursing assistants regarding coercive measures and medication before other nursing measures had been evaluated. Some of the participants also stated that they felt questioned in their competence and profession, which constituted an obstacle to their ethical considerations. It emerged that not only pressure from nursing assistants but also disrespectful treatment from doctors led to some of the psychiatric mental health nurses feeling lonely in their profession and in their ethical assessments.

“ I’ve been pressured by nursing assistants who think that if a patient becomes aggressive and threatening, then it’s mechanical restraints and injections that should be resorted to; there aren’t a lot of alternatives, sort of. And then I think that it has a lot to do with ignorance. ” (Participant 9).

Some participants gave examples of how doctors sometimes showed a lack of respect in coercive situations by giving the injection to the patient when the nurse had made a different assessment and did not consider the measure ethically justified. Another participant stated that a doctor had threatened to report if the coercive measure was not carried out as prescribed. A third participant stated that doctors occasionally threatened uncompromising patients with the use of belts even though there was no indication for such a measure.

“ Sometimes on-call doctors enter and prescribe before they have listened, they have heard us but not listened. Some of them have already made their minds up when they hear the patient’s name. Taking their cue from earlier experiences [of the patient] .” (Participant 6).

The majority of the participants claimed that due to a lack of staff, the staff could not always perceive shifts in the patient’s mood and were thus unable to divert and calm the patient in time. In these situations, there was an increased risk of coercive measures, and the psychiatric mental health nurses’ ethical considerations were about protecting patients from unfair treatment and unnecessary suffering caused by staff shortages.

Lack of understanding of the psychiatric mental health nurse’s ethical dilemmas

It emerged during the interviews that there was a need for an increase in ethical competence in the organization, as many of the participants were alone in their ethical considerations regarding coercive measures. The participants felt that by raising the staff’s ethical competence, the understanding of the psychiatric mental health nurses’ profession and of their ethical considerations could increase. The majority of the participants also felt that more experienced nurses were needed. The less experienced psychiatric mental health nurses were affected to a greater extent by the other nurses’ opinions rather than trusting their own assessments.

“ It would have been good with more nurses. Nursing assistants who have worked for many years may easily influence new nurses … and the new [nurses] maybe don’t really dare be assertive about themselves and their judgements .” (Participant 9).

Several participants stated that there was an ongoing ethical discussion among nurses in the workplace, but that, although there was time for reflection, not all staff members participated. On the other hand, many participants asserted that they had support from colleagues and opportunity for discussion in the work team after a troublesome coercive situation. Nevertheless, many of the participants requested an ethical discussion forum organized by the employer. A majority believed that ethics rounds would contribute to a higher ethical awareness, which in turn could lead to a better response to and a greater understanding of the patient’s situation as well as of the psychiatric mental health nurses’ ethical dilemmas.

“ But we nurses talk a lot about it [ethics], about being hospitalized in psychiatric inpatient care, [about how] that very fact means that there should be great acceptance of their not behaving like people in the street .” (Participant 10).

Some participants wished for a greater ethical commitment on the part of the employer, but at the same time they felt that this was not prioritized.

All participants stated that ethical considerations, based on ethical principles and on the desire to preserve the patient’s autonomy as far as possible, were applied in their work with patients. The results showed that the psychiatric mental health nurses did everything to increase the patient’s participation and autonomy. It emerged that when the purpose of a particular measure could not be communicated, this led to violation of the patient’s autonomy and a decrease in patient participation. Previous studies [ 30 , 31 ] emphasize the importance of good communication in order to build a genuine and meaningful relationship between patient and nurse. Results from the present study showed that patient participation was highly valued in order to maintain and increase patient autonomy, and that the psychiatric mental health nurses strived to avoid coercive measures.

The aforementioned desire to preserve the patient’s autonomy and dignity by involving the patient as much as possible in the decisions regarding their care, could be a reason to introduce the question regarding autonomy and coercive measures already in the care plan for outpatients or at admission. This is highlighted in a review by Chieze et al. [ 32 ], where it is suggested that by discussing coercive measures with the patient and involving the patient in the care planning phase, the patient may agree with the caregiver that coercion is the best way to overcome a mental crisis. By adhering to such a procedure, coercion can be seen as a way to enhance the patient’s condition in certain circumstances, which is in line with the view expressed by the participants in the present study, namely, that coercion can sometimes be used to decrease suffering both short and long term.

Lack of ethical awareness negatively affected ethical considerations and therefore counteracted the patient’s autonomy. Inadequate ethical competence among colleagues led to ethical conflicts and increased moral stress, as also shown in a study by Pauly et al. [ 33 ]. According to Eren [ 34 ], negative attitudes may influence the psychiatric mental health nurse’s relationship with the patient, and a deteriorating relationship may lead to restrictions on patient autonomy. Another conclusion in Eren’s [ 34 ] study was that nurses in psychiatric care needed further ethical education. The results of the present study showed a desire to increase ethical competence within the entire care organization, so that everyone in the team would become more involved and gain understanding of the psychiatric mental health nurses’ ethical dilemmas and considerations. As demonstrated in a review by Paradis-Gagné et al. [ 35 ], decisions regarding coercive measures should be made in careful consultation with team members, while minimizing the restriction of patient autonomy. Furthermore, previous studies [ 35 , 36 ] showed that a common ethical value base within the care team is crucial for fulfilling the patient’s wishes for a genuine meeting between patient and staff and for the promotion of the patient’s autonomy. This is in line with our study participants’ view that ethics rounds and an ethical commitment on the part of the organization management would be of great value. Ethics rounds may foster cooperation among the staff and make them learn to see things from different perspectives, which in turn may influence patient care [ 37 ]. In conclusion, the integration and application of ethical awareness in the mental health care organization and of ethical values among mental health staff may be beneficial for patients’ autonomy and participation when coercive measures are needed.

Clinical implications

In this study, patient participation was highly valued by all psychiatric mental health nurses, in order to maintain as well as increasing patient autonomy. One way to increase the patient’s autonomy could be to discuss a possible coercive measure already in the care plan. Even if the psychiatric mental health nurses always strive to avoid coercive measures, the patient may, in certain circumstances, agree with the caregiver that coercion is the best way to overcome a crisis. Another clinical suggestion is to introduce ethics rounds in addition to medical rounds. According to a majority of the study participants, ethics rounds could improve ethical awareness among the staff and thereby also improve the staff’s response to and understanding of both the patients’ situation and the psychiatric mental health nurses’ ethical dilemmas.

Limitations

Graneheim et al. [ 38 ] highlight the challenge of using qualitative content analysis in research. Maintaining a “common thread” throughout the study, as well as enabling the reader to distinguish the voice of the researcher from that of the participants, is necessary for establishing rigor [ 38 ]. Therefore, it was important for the researchers in this study to thoroughly describe design and method, as well as setting and participants, and to use quotations from the interviews. One limitation of the study may be the number of participants, and a sample of twelve may be considered small. However, according to Malterud et al. (2016), the more information a sample holds, the lower the required number of participants [ 39 ]. Another limitation could be that the participants worked in a limited geographical region, which could affect the result since working methods, education, and ethical awareness may vary between regions. However, data from qualitative interview studies are not aiming for generalizability.

We found strong agreement that all psychiatric mental health nurses in our study actively consider ethical dilemmas connected to coercive measures. Coercive measures were only used in exceptional circumstances and the respect for the patient’s autonomy was prominent in the ethical reasoning of all the psychiatric mental health nurses. The four ethical principles, involving respect for autonomy, beneficence, nonmaleficence, and justice, were constantly present in their ethical considerations. Coercive measures were seen as justified in both a short- and a long-term perspective to alleviate patients’ suffering. Obstacles to ethical considerations were professional loneliness and lack of understanding on the part of other staff members about the psychiatric mental health nurses’ ethical dilemmas. Theoretical knowledge about ethical concepts was asked for.

Availability of data and materials

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

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The authors wish to gratefully thank the participating nurses who generously shared their experiences.

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Charlotta Manderius

Psychiatric psychosis unit, adult psychiatry, Region Skane, Helsingborg, Sweden

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CM, KC, KS, and KÖ together formulated the aim and design of the study, CM and KC collected the data, and CM, KC, KS, and KÖ all participated in the analysis and interpretation of the data. CM, KC, and KÖ drafted the paper.

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Manderius, C., Clintståhl, K., Sjöström, K. et al. The psychiatric mental health nurse’s ethical considerations regarding the use of coercive measures – a qualitative interview study. BMC Nurs 22 , 23 (2023). https://doi.org/10.1186/s12912-023-01186-z

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MODULE 6: LEGAL AND ETHICAL ISSUES

Legal and ethical issues.

This module aligns with key elements of APNA’s “Ethical and Legal Principles” (American Psychiatric Nurses Association Education Council, Undergraduate Branch, 2022).

Module Outline

Legal issues related to mental illness, patient’s rights.

• Ethical Issues Related to Mental Illness

Module Learning Outcomes

• Describe how nursing interacts with law
• Describe issues related to voluntary versus involuntary commitment
• Outline patient’s rights.
• Clarify concerns related to the therapist-client relationship

In this module, we will tackle the issue of how nursing interacts with law. Our discussion will include topics related to voluntary versus involuntary commitment, patient’s rights, and the patient-therapist relationship.

Watch this video for a summary of nursing issues related to the law.

Level Up RN. (2022). Psychiatric mental health nursing: introduction, patient rights [Video]. YouTube. https://youtube.com/watch?v=ZsEyrOWH6Mk&si=EnSIkaIECMiOmarE

Civil Commitment

When individuals with mental illness behave in erratic or potentially dangerous ways, to either themselves or others, then something must be done. Action involves involuntary commitment in a hospital or mental health facility and is done to protect the individual and express concern over their well-being, much like a parent would do for their child. An individual can voluntarily admit themselves to a mental health facility, and upon doing so, staff will determine whether or not treatment and extended stay are needed.

Criteria for Involuntary  Commitment

Though states vary in the criteria used to establish the need for involuntary commitment , some requirements are common across states.

• First, the individual must present a clear danger to either themselves or others.
• Second, the individual demonstrates they are unable to care for themselves or make decisions about whether treatment or hospitalization is necessary.
• Finally, the individual believes they are about to lose control, and so, needs treatment or care in a mental health facility.

Procedures in Involuntary Commitment

The process for involuntary commitment does vary a bit from state to state, but some procedures are held in common.

• First, a family member, mental health professional, or primary care practitioner, may request that the court order an examination of an individual. If the judge agrees, two professionals, such as a mental health professional or physician, are appointed to examine the person in terms of their ability for self-care, need for treatment, psychological condition, and likelihood to inflict harm on self or others.
• Next, a formal hearing gives the examiners a chance to testify as to what they found. Testimonials may also be provided by family and friends, or by the individual him/herself. Once testimonies conclude, the judge renders judgment about whether confinement is necessary and, if so, for how long. Typical confinements last from 6 months to 1 year, but an indefinite period can be specified too. In the latter case, the individual has periodic reviews and assessments.
• In emergencies, the process stated above can be skipped and short-term commitment made, especially if the person is an imminent threat to him/herself or others.

In an emergency situation , where an individual has expressed threats of harm to themselves or another person, most states have laws that permit involuntary commitment for 48-72 hours to ensure the patient’s safety.

Patients admitted to a psychiatric treatment facility maintain all their civil rights with one exception ; if they have been admitted involuntarily, they may not be able to leave the facility (Videbeck, 2020).  The following are several rights pertaining to patients and mental health treatment settings.

See this article (American Psychiatric Association, n.d.) for further reading.

A summary of these rights as included in Videbeck (2020) include:

• Right to Information related to treatment options, providers’ qualifications, appeals and grievance procedures
• Right to Refuse Treatment 
• Right to Least Restrictive Environment to Meet Needs
• Choice of Providers
• Confidentiality
• Nondiscrimination
• Hold Accountable Professionals and Payers responsible for injury associated with incompetence, negligence, or unjustified decisions
• Treatment is Determined by Professionals not third-party payers

The Therapist-Client Relationship

Two concerns are of paramount importance in terms of the therapist-client relationship. These include the following:

• Confidentiality – As you might have learned in an introductory nursing course, confidentiality guarantees that information about the patient is not disseminated without their consent. Health Insurance Portability and Accountability Act (HIPAA) also guides nurses’ when and who should receive information concerning individuals admitted to a psychiatric treatment facility. See the resource located under “Additional Resources” below.
• Duty to Warn – In the 1976 Tarasoff v. the Board of Regents of the University of California ruling, the California Supreme Court said that a patient’s right to confidentiality ends when there is a danger to the public, and that if a therapist determines that such a danger exists, there is an obligation to warn the potential victim. Tatiana Tarasoff, a student at UC, was stabbed to death by graduate student, Prosenjit Poddar in 1969, when she rejected his romantic overtures, and despite warnings by Poddar’s therapist that he was an imminent threat. The case highlights the fact that therapists have a legal and ethical obligation to their clients but, at the same time, a legal obligation to society. How exactly should they balance these competing obligations, especially when they are vague? The 1980 case of Thompson v. County of Alameda ruled that a therapist does not have a duty to warn if the threat is nonspecific.

Additional Resources

What resources are there for application of HIPAA within a mental health facility?

• Check out this webpage to answer this question (U.S. Department of Health & Human Services, n.d.)

Key Takeaways

You should have learned the following in this section:

• Civil commitment occurs when a person acts in potentially dangerous ways to themselves or others and can be initiated by the person (voluntary commitment) or another professional (involuntary commitment).
• Patients admitted involuntarily to a psychiatric treatment facility maintain all civil rights with the exception of the right to leave. The American Psychiatric Association also established a Bill of Rights for mental health patients.
• There are two main concerns which are important where the therapist-client relationship is concerned – confidentiality and the duty to warn.

MENTAL HEALTH IS A VERB Copyright © 2023 by Jake Bush and Jill Van Der Like is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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7 Ethical and Legal Issues in Mental Healthcare

• Published: May 2022
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Mental health trainees are sometimes surprised by the weighty legal and ethical responsibilities they face. The purpose of this chapter is to introduce significant legal and ethical dilemmas so that trainees are not caught unaware later on. The issues addressed include maintaining professional boundaries, protecting confidentiality, managing mandatory reporting of child or elder abuse, and assessing for suicide or homicide risk. Brief case vignettes are used to illustrate some of the challenges in ethical decision-making. The consequences of ethical violations are briefly reviewed, and a suggested model to guide ethical decision-making is provided. The intersection of academic, research, and mental health ethical codes is discussed. Finally, readers are urged to pursue aspirational ethics beyond just adherence to laws and ethical codes. Aspirational ethics include advocacy for social and racial justice, as well as other social, environmental, human rights, health, or economic causes.

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Key Concepts and Issues in Nursing Ethics pp 145–157 Cite as

Ethical Issues in Mental Health Nursing

• Grahame Smith 2  
• First Online: 09 March 2017

7057 Accesses

This chapter explores mental health nursing practice within an ethics context. It teases out the ethical challenges that mental health nurses can face on a daily basis. A short case-study highlights potential solutions to those challenges.

For mental health nurses having the power to control and being expected to control people diagnosed with a mental disorder can be morally distressing, especially where situations do not always have clear outcomes. The case-study part of the chapter will consider how in these difficult circumstances mental health nurses can control and potentially restrict service user freedoms in a way that reduces moral distress and is beneficent and sensitive. A challenge for the contemporary mental health nurse is to know how to wield this power in a way that acknowledges their societal responsibilities while at the same time respecting the rights of the individuals they are required to control. It is important to recognise that restricting freedoms through the use of sanctioned coercion can be a good thing, however this is dependent on coercion being used by the mental health nurse in a way that is sensitive to the needs of the mental health service user.

• Mental health nursing
• Ethical reasoning
• Values-based practice
• Expert practice
• Emotional intelligence

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While recognising the debate in the literature around nomenclature patient / client / service user, see for example chapter seven of this book, the term service user is the term used in this chapter as that in most common usage in mental health care contexts in both Ireland and the UK.

Principlism describes an approach to ethical decision-making using ethical principles; such as the four-principle approach of Beauchamps and Childress ( 2013 ) cited above.

Anderson S (2011) Coercion. http://plato.stanford.edu/entries/coercion/ . Accessed 10th June 2016

Armstrong AE (2006) Towards a strong virtue ethics for nursing practice. Nurs Philos 7:110–124

Article   Google Scholar  

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Smith, G. (2017). Ethical Issues in Mental Health Nursing. In: Scott, P. (eds) Key Concepts and Issues in Nursing Ethics. Springer, Cham. https://doi.org/10.1007/978-3-319-49250-6_11

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Special Report: Ethical Decision-Making in Contemporary Psychiatric Practice—An Evolving Challenge

• Laura Weiss Roberts , M.D., M.A. ,
• Gabriel Termuehlen , B.A.

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Psychiatrists face a distinct set of ethical challenges and professional obligations related to their work. Issues of beneficence, nonmaleficence, confidentiality, altruism, justice and nondiscrimination, professionalism, trust, and related abstract concepts emerge regularly in their treatment of patients.

What ethical issues might arise when a psychiatrist includes artificial intelligence decision tools in her clinical practice?

Why, and how, should one intervene when a colleague is potentially impaired?

In what ways can one safeguard the autonomy of a patient who is living with a severe but intermittent disorder affecting mood and cognition? What ethical tensions might one anticipate and prepare for?

Psychiatrists regularly confront both age-old and new questions in their practice, from those that involve the cornerstone values of beneficence and respect to those that involve the cutting edge of technological innovation.

Ethics is a formal branch of philosophy that seeks to more deeply understand the moral aspects of human nature and action. Within the profession of medicine, ethics has evolved into an applied discipline. Medical ethics is rooted in formal research and evidence as it emerges from everyday clinical practice, as well as in historical concepts that have endured and evolved over many centuries, such as autonomy, beneficence, nonmaleficence, and justice. This discipline includes specific clinical skills that are as crucial to being a competent and compassionate physician as taking a careful history, evaluating symptoms, and forming a diagnosis.

Closely allied with ethics is the concept of professionalism. Professionalism is intrinsically grounded in the ideals of a profession (such as truthfulness, respect for dignity of patients, and humility), although how such ideals are expressed at any given moment in history and in different contexts will change. A profession has moral importance because of the trust and privileges conferred on it by society. Being a member of a profession has moral standing because society requires that professionals possess certain qualities and adhere to a set of duties. The good conduct of members of a profession confirms the investment of power that society has placed in them and in their field, fostering a relationship of trust and equipoise.

Psychiatrists face a unique set of ethical challenges and professional obligations related to the specifics of their work. They confront issues of personhood and autonomy, continuously grappling with definitions of health and illness and the very components that make up behavior and identity. Ethical issues of beneficence, nonmaleficence, confidentiality, altruism, justice and nondiscrimination, professionalism, trust, and other seemingly abstract concepts regularly emerge in the daily work of psychiatrists.

The second edition of Professionalism and Ethics, Second Edition: Q & A Self-Study Guide for Mental Health Professionals , newly published by American Psychiatric Association Publishing, seeks to encompass everyday ethical challenges with a focus on clinical skills. These skills, like any other, require practice, as past APA President Paul Appelbaum, M.D., emphasizes in a wise introductory comment to the book.

“Just as good people do not instinctively follow good diagnostic practices without the training required to do so, just as they cannot be expected to have an intuitive sense of interactions among medications without studying pharmacology, so good people are not necessarily able to avoid the pitfalls inherent in the ethical challenges ubiquitous in clinical work,” Appelbaum writes. “Sound ethical practice, like good psychotherapy, requires a judicious mixture of theoretical knowledge, supervised learning, and reflective practice. And like most other aspects of the job of a clinician, learning ethics takes time and intellectual effort.”

New Ethical Challenges in an Evolving Landscape

Each decade brings new, unexpected ethical challenges that evolve over time. Among them:

The Neuroscience Revolution

Over the past few decades, neuroscience has taken up a central role in medicine as the conceptual basis for understanding and treating people with mental illness. The study of the brain’s functioning and the recursive application of advancements in our metacognitive understanding to influence the brain and mind carry ethical questions that are not present elsewhere in the biological sciences. These questions belong to the emerging field of “neuroethics.”

Examples of topics in neuroethics include the following:

Emerging biomedical and neuroimaging technologies

Mobile health technology and wearable devices

Neuromodulation

Neurotechnology research

The role of technology in the lives of young people

Brain death and the definition of death

Ethical issues in neurodegenerative conditions

Environmental neuroethics

Neurobiology of addiction

Neuroscience and the law

Novel Tools and Treatments

Ethical issues accompany the advent of any new diagnostic and evaluative tools. Advances in genetics, genomics, and other biomarkers (such as neuroimaging) hold the potential to bring the practice of psychiatry into the realm of “precision medicine.” Precision psychiatry will raise issues of autonomy (does the patient fully comprehend and voluntarily agree to the use of the diagnostic tool or method?); beneficence (will such novel diagnostic schema have clear benefits for the patient?); nonmaleficence (are there any foreseeable harms associated with the new methods?); and justice (is access to novel diagnostic or evaluative methods fair and nonexploitative of vulnerable populations?).

Psychiatric researchers are also exploring a range of novel therapeutic approaches to address unmet needs in patients with mental illness. For example, investigations are ongoing into the potential use of psychedelic compounds (such as psilocybin) for treatment-resistant depression. Novel neurosurgical approaches are also being evaluated for their efficacy in treating patients with psychiatric conditions (including substance use disorders, eating disorders, and neurocognitive disorders). These endeavors raise a number of ethical issues including the following:

Ensuring that patients enrolling in novel therapeutics trials provide informed, authentic consent

Ensuring that protocols (whether in the research or treatment context) are designed with adequate safeguards for both known potential risks and unforeseen adverse events

Disseminating accurate, judicious information about the known benefits and risks of these emerging therapies

The Digital Revolution and Use of ‘Big Data’

Emerging methods of prediction in clinical care are bringing a range of new ethical questions to the forefront. The use of machine learning and artificial intelligence to predict illness course or the possibility of specific behaviors (including suicide attempts) may affect the patient-clinician relationship in unexpected ways, for example, by influencing treatment decision-making or the allocation of resources.

Algorithmic bias poses great risk in decision-making involving machine learning algorithms, as it can operationalize biases already at work in human decision-making under the guise of sophistication. Transparency about when algorithms are being used and how such algorithms affect patient confidentiality are extremely important. Ensuring adequate communication with patients about algorithms and obtaining proper informed consent are also crucial. It is unfortunate that many algorithms are developed without adequate transparency to stakeholders. Clinicians should consider how algorithms were trained and whether appropriate safeguards were implemented to protect against bias in the context of training (for example, ecological validity of the training data and choice of learning model). There is very little consensus about how to ethically utilize algorithms in clinical care, including for mental health applications.

Assisted-Suicide and Physician-Assisted Death Laws

In recent years, the topic of physician-assisted dying (also known as medical aid in dying and physician-assisted suicide) and the related (but distinct) practice of euthanasia have become contentiously debated issues in the United States and many other countries. Physician-assisted dying refers to a physician’s providing either the means or information necessary for a patient to end his or her life. Euthanasia refers to the termination of life by a physician or another clinician. From ethical and legal points of view, assisted dying and euthanasia are distinct from withholding or withdrawing care necessary for continued life. Additionally, assisted dying and euthanasia are viewed as different from administering medications to relieve pain or to bring greater comfort, as the primary intention in this case is not to end the patient’s life. In the United States, physician-assisted dying is legal in some states, while euthanasia remains illegal across the country. APA released a statement in 2016 stating that “a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”

Concerning data have been reported regarding the use of assisted dying and euthanasia in some European countries for individuals with psychiatric and neurocognitive disorders. Commentators in certain countries have suggested that extending eligibility criteria for euthanasia beyond “reasonably foreseeable natural death” to include psychiatric illnesses could result in ethical conflicts between a patient’s desire to end suffering and limitations in access to specialized psychiatric care, send the implicit message that individuals with chronic or severe psychiatric illnesses do not have lives worth living, erode the ethical principle of nonmaleficence, and contribute to provider moral distress and burnout.

Equitable, Patient-Centered Care

The need to include all voices as full partners in clinical care—including individuals with lived experience of mental illness, individuals who seek mental health care services, and underrepresented populations—represents a crucial ethical challenge for psychiatrists today. However, this challenge is “new” only to the extent that it is, at last, more widely recognized and acknowledged; structural inequities in access to care, the quality of care that patients receive, and inequities in research have plagued medicine and psychiatry for generations. Successfully negotiating this moral territory requires a departure from prior, more hierarchical and paternalistic models of care. Mental health professionals need a new set of skills, including the ability to mediate disputes, negotiate power sharing, manage more complex legal situations, and participate in struggles for social justice and political parity, without which adequate mental health care and its funding cannot be achieved.

Social Media

Online platforms and media bring new opportunities and challenges. All psychiatrists need to make conscientious and informed choices about whether, how, what, and how much to interact and disclose online. Given that the majority of psychiatry trainees, and an increasing number of physicians, have social media accounts, outright avoidance or rejection of social media has become impractical. Moreover, these sites now play integral and positive roles for many physicians as facilitators of social interaction. Furthermore, if psychiatrists act carefully and proactively, they can maintain their standards of ethics and professionalism online and ensure appropriate boundaries. Suggested guidelines center around basic issues of trust, privacy, professional standards of conduct, and awareness of potential implications of all digital content and interactions. Simply put, online expression should be viewed as “the new millennium’s elevator,” where psychiatrists have little control over who hears what they say.

Where the Rubber Meets the Road: Clinical Skills and Ethical Decision-Making

Mental health professionals tend to rely on a set of six core ethics skills. The ability to recognize ethical issues requires some familiarity with key ethics concepts and the interdisciplinary field of bioethics. As a corollary, this ability presupposes the clinician’s capacity to observe and translate complex phenomena into patterns, using the common language of the helping professions (for instance, conflicts among autonomy, beneficence, and justice when a person with mental illness threatens the life of a specific individual and is thus involuntarily held for evaluation).

The first of these core skills is the ability to identify ethical issues as they arise. For some, this is an intuitive insight—that is, an internal sense that something is not right—and for others this is derived more logically.

The second key ethics skill is the ability to understand how one’s personal values, beliefs, and sense of self may affect one’s care of patients. Attentiveness to interpersonal aspects of the clinician-patient relationship is a crucial safeguard for ethical decision-making by professionals to serve the needs and best interests of patients. In recent years, the role of implicit bias has been identified and studied vigorously, demonstrating the influence of attitudes and social stereotypes related to gender, race, cultural background, and other aspects of identity on many aspects of health care. The impact of implicit bias is felt by patients and health professionals and can adversely affect patient care practices, quality, safety outcomes, and health system policies.

The third key ethics skill is an awareness of the limits of one’s own medical knowledge and expertise and the willingness to practice within those limits.

The fourth skill is the ability to recognize high-risk situations in which ethical problems are likely to arise. Such circumstances can occur when a mental health professional must step out of the usual treatment relationship to protect the patient or others from harm or to protect the patient’s or others’ best interests, even when the patient may not agree.

The fifth skill is the willingness to seek information and consultation when faced with an ethically or clinically difficult situation and the ability to make use of the guidance offered by these sources.

The sixth and final essential skill for the mental health professional is the ability to build appropriate ethical safeguards into one’s work.

Many clinicians use an eclectic approach to ethical problem-solving that makes intuitive use of principles, case experiences, lessons learned from colleagues, and a combination of inductive and deductive reasoning. Such an approach typically yields not one “right” answer but, rather, an array of possible and ethically justifiable responses that may be acceptable in the specific set of circumstances.

A more systematic and explicit approach widely used in the clinical setting is the four-topics method described by Albert Jonsen, Ph.D., and colleagues in the influential 2002 text Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine . This method entails gathering and evaluating information about (1) clinical indications, (2) patient preferences, (3) patient quality of life, and (4) contextual or external influences on the ethical decision-making process.

Many ethical dilemmas in clinical care involve a conflict between clinical indications and patient preferences. Working through such a dilemma requires exploring fully and thoughtfully the patient’s preferences as well as the clinical indications.

Why does the patient refuse treatment? Does the patient have the capacity to make this decision at this time? Is there a range of options, perhaps some that have not been previously considered, that may offer benefit? How urgent is the clinical situation, and is time available for discussion, collaboration, and perhaps compromise?

If the patient lacks decision-making capacity, the dilemma is at least temporarily resolved by identifying an appropriate alternative decision-maker. If the patient does have the ability to provide informed consent—involving capacity for decision-making and capacity for voluntarism—then, under most foreseeable circumstances, the patient’s preferences must be followed. However, by engaging the patient in a meaningful dialogue in which the mental health professional describes the full range of treatment options and demonstrates sensitivity to the reasons for the patient’s refusal, it may often be possible to discover a solution that the patient can willingly accept and the clinician can justify as medically beneficial.

Informed consent is the process by which individuals make free, knowledgeable decisions about whether to accept a proposed intervention, such as clinical care or research study participation. Informed consent is thus a cornerstone of ethical practice in both treatment and research settings. Although informed consent is a legal requirement in both contexts, its philosophical roots as a medicolegal doctrine are deeply embedded in our societal and cultural respect for individuals and in affirming individuals’ freedom of self-determination. An adequate process of informed consent thus reflects and promotes the ethical principle of autonomy.

A model of shared, deliberate decision-making fits with a larger commitment to patient-centered care. Shared decision-making and patient-centered care are grounded in the principle of respect for persons and demonstrate deep regard for the dignity of individuals who receive clinical care. Actions that promote shared decision-making include ensuring that patients are well informed, encouraging patients to play a direct role by making choices and making clear the values and preferences underneath these choices, and protecting and supporting patients’ interests.

Every era of medicine has ethical challenges—some new, such as we have experienced with the COVID-19 pandemic and effects of recent extreme weather events caused by climate change, and some not as new, such as how to uproot systemic barriers to equity in the workplace and in the provision of care and how to demonstrate respect for patients’ cultural values, self-governance, and privacy.

Psychiatrists and other clinicians caring for people with mental illness and substance use disorders encounter additional and specific ethical concerns, also modern and ancient. The questions and quandaries posed by these ethical issues in everyday clinical practice are thorny, sometimes challenging our own deeply held attitudes and beliefs and engaging the most fundamental aspects of what it means to be a physician.

The answers to these problems are nuanced and dependent on multiple factors and context. For these reasons, psychiatrists, trainees, and practitioners in related health fields must understand the requirements of professionalism and cultivate a strong set of skills for making sound ethical decisions. ■

WHAT WOULD YOU DO?

Case 1: psychiatrist asked to treat an acquaintance.

A 19-year-old has been isolated at home for several weeks after graduating from high school. Her plans for college shifted because of her family’s financial situation and because of an infectious disease pandemic. She made one phone call in an effort to get mental health care, but she could not find sufficient privacy in her home, which is a small apartment. She reached out to a high school friend whose father is a psychiatrist and asked if it would be possible to text the psychiatrist from time to time and to get a prescription for antidepressant medications.

What ethical issues and conflicts are present in this clinical scenario?

What contextual factors are influencing the situation and the decision and options available to the psychiatrist?

What kinds of potential risks exist for this psychiatrist in providing care in this particular situation?

How might you handle this situation? What are the most important next steps for the psychiatrist?

What other expertise or resources may be introduced to help or address ethical issues or professionalism challenges in this situation?

Case 2: Psychiatrist Feels Overextended at Work

A 68-year-old psychiatrist is the sole mental health professional in a multispecialty group practice. The group practice has become increasingly busy: The volume of referrals to the psychiatrist has grown dramatically, and the kinds of patient care situations have become much more severe since a local inpatient unit was closed. The psychiatrist is concerned about stress and has noticed that his notes are not as complete and that he awakens at night, worrying over questions he forgot to ask or problems he failed to address in caring for patients the previous day.

What contextual factors are influencing the situation and the decisions and options available to the psychiatrist?

What kinds of potential risks exist for patients and for this psychiatrist in this particular situation?

Case 3: Psychiatry Resident Wishes to Improve Patient Care

An addiction psychiatry trainee is on a three-month rotation in which she provides care for patients in a general mood disorders clinic. She notices that one of the teaching attending psychiatrists seldom asks about addiction-related issues and never asks about safety in the home when evaluating patients. She wishes to raise her concerns, especially regarding female patients with multiple health issues, but she feels very intimidated by the attending psychiatrist, who always seems stressed, irritable, and quick to offer a harsh or negative comment.

What kinds of potential risks exist for patients and for the psychiatry trainee in this particular situation?

How might you handle this situation? What are the most important next steps for the psychiatry trainee?

Case 4: Psychiatrist ‘Stretches’ to Deal With System Challenges

A psychiatrist accepts a telehealth contract to provide consultations on psychiatric patients who come to emergency rooms in a five-county region. The psychiatrist has a full-time “day job” but felt he could handle the extra work and hoped to be able to pay off his school debt more quickly by accepting the added role. The emergency rooms are located in urban and rural community hospitals, which are typically understaffed, and the number of patient evaluations per contracted shift may range from four to 18. The psychiatrist loves the work and feels he is helping to identify patients who are in the greatest immediate need for psychiatric expertise. He also enjoys working with his emergency medicine colleagues, even in this limited way, but worries that a brief telehealth visit does not really help patients in the long run and is just a “Band-Aid” on an inadequate system.

What ethical issues are present in this clinical scenario?

What inherent risks exist in this situation?

How are the psychiatrist’s roles as clinician, colleague, and advocate relevant in this scenario?

Case 5: Chief Resident Intervenes to Address Team Member Distress

A medical student rotating through a psychiatry emergency/crisis clinic for a third-year clerkship becomes extremely distraught after seeing a patient (with the attending psychiatrist) who described her experience surviving childhood sexual abuse. Recognizing the student’s distress, the chief resident met with the student. The student described being upset by the patient’s personal story and the attending psychiatrist’s manner, which the student felt was “insensitive” because of the psychiatrist’s efforts to direct the patient to the “here and now.”

How are the student’s, attending psychiatrist’s, and chief resident’s roles and professional duties influencing the ethical dimensions of the situation?

If you were the chief resident, how might you handle this situation? What are the most important next steps?

Case 6: Psychiatrist Asked to Treat VIP Patient

A psychiatrist receives a VIP referral from a primary care colleague. The VIP patient is a well-known celebrity who is frequently featured in the news and on social media. The patient is experiencing extreme anxiety after a recent event that “went viral” online. The psychiatrist recognizes the patient’s name and is tempted to investigate the patient’s background and circumstances prior to the initial evaluation.

How might you handle this situation? What are the most important next steps?

Case 7: Psychiatrist Wants to Review Patient Records for Possible Research Project

A psychiatrist wishes to conduct a quality assurance project that will involve reviewing the electronic medical records of recent psychiatric inpatients to verify the presence of appropriate documentation of sexual history, suicidality, and substance use. The psychiatrist is hoping that eventually there will be an interesting research project to come out of the quality assurance work.

What issues should the psychiatrist consider in setting up appropriate safeguards for the quality assurance project? And if it becomes a research project? What are the most important next steps?

Laura Weiss Roberts, M.D., M.A.

Conflict of Interest Disclosure 2021

Dr. Laura Roberts serves as the Chairman and Katharine Dexter McCormick and Stanley McCormick Memorial Professor in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine.

Dr. Roberts has received federal funding for competitive, peer-reviewed research grants and competitive, peer-reviewed small business grants and contracts. The key stakeholders, such as Stanford University and the NIH, are fully aware of this arrangement and have given prior approval for this set of professional commitments. In addition, she often serves as a consultant for federally funded scientific projects with collaborators across the United States.

Dr. Roberts is the Editor-in-Chief, Books for the American Psychiatric Association Publishing. Funds associated with these duties are provided to Stanford University.

Dr. Roberts is the Editor-in-Chief of Academic Medicine, a peer-review publication of the Association of American Medical Colleges. She receives a stipend for this professional service to the AAMC.

Dr. Roberts does not receive direct funding from pharmaceutical companies for her work and she is not on any “Speakers’ Bureaus” of any kind. She does give academic and public/community talks for which she receives honoraria.

Dr. Roberts has published books and receives royalties. These royalties represent a very small proportion of Dr. Roberts’ overall income. Dr. Roberts has owned Terra Nova Learning Systems (TNLS), a small company that developed science-based educational products in the past.

Laura Weiss Roberts, M.D., M.A., is chair of the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine and the Katharine Dexter McCormick and Stanley McCormick Memorial Professor of Psychiatry. She is the co-editor of Professionalism and Ethics, Second Edition: Q & A Self-Study Guide for Mental Health Professionals and editor-in-chief of the books division of APA Publishing.

Gabriel Termuehlen, B.A., is an editor in the Department of Psychiatry and Behavioral Sciences in the Stanford University School of Medicine and the book’s co-editor. APA members may purchase the book at a discount here .

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5: Legal and Ethical Considerations in Mental Health Care

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• 5.1: Introduction
• 5.2: Ethical Principles
• 5.3: Standards of Care
• 5.4: Laws, Torts, Malpractice, and Disciplinary Actions
• 5.5: Patient Rights
• 5.6: Learning Activities
• 5.7: V Glossary

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Patients with severe mental illness and the ethical challenges related to confidentiality during family involvement: A scoping review

Marit helene hem.

1 Norwegian University of Science and Technology (NTNU) Social Research, Trondheim, Norway

2 Faculty of Health Studies, VID Specialized University, Oslo, Norway

Bert Molewijk

3 Centre for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway

4 Department Ethics, Law and Humanities, Amsterdam University Medical Centre (UMC) and Vrije Universiteit, Amsterdam, Netherlands

Bente Weimand

5 University of South-Eastern Norway, Faculty of Health and Social Sciences, Drammen, Norway

6 Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway

Reidar Pedersen

Associated data.

Despite evidence on the significant potential value of family involvement during the treatment of patients with severe mental illness, research has shown that family involvement is largely underused. The duty of confidentiality is reported to be a key barrier to family involvement. To develop more insight into this barrier, this scoping review focuses on the following question: What are the reported ethical challenges related to confidentiality when involving family in the treatment of patients with severe mental illness?

A systematic search into primary studies was conducted using the following databases: Medline (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), and Web of Science core collection (Clarivate). The PICO (Population, Intervention, Comparison, Outcome) scheme and qualitative content analysis were used to make the ethical challenges more explicit.

Twelve studies—both qualitative and quantitative—were included. We identified the following main categories of ethical challenges: (1) the best interest of family members vs. confidentiality, (2) the patient's best interest vs. the right to confidentiality, (3) patient trust and alliance as a reason not to involve the relatives or not to share information, and (4) using confidentiality as a smokescreen. We also identified several subcategories and illustrative and concrete examples of ethical challenges.

Conclusions

Through a systematic examination, we discovered various types of ethical challenges related to confidentiality when involving the family in the treatment of patients with severe mental illness. However, research on these ethical challenges and the constituents of these challenges remains limited and often implicit. An ethical analysis will create knowledge which may facilitate a more balanced and nuanced approach to respecting the principle of confidentiality while also considering other moral principles. The duty of confidentiality does not always have to be a major barrier to family involvement; this insight and using this ethical analysis in the training of healthcare professionals may benefit the patient, the family, and the services.

Introduction

While researchers ( 1 ) and international health authorities ( 2 – 6 ) widely recognize family involvement as a key ingredient in mental healthcare for patients with severe mental illness, the inclusion of family and next of kin is often lacking or inadequate ( 1 , 7 , 8 ).

Important and frequently reported barriers to family involvement for patients with severe mental illness include patients' concerns about privacy ( 9 ) and healthcare professionals' duty of confidentiality ( 1 ). Health professionals argue that the duty of confidentiality takes precedence over relatives' need for information and involvement, while relatives claim that health professionals use the duty of confidentiality to avoid true collaboration (ibid.). Though confidentiality is one of the oldest and most renowned healthcare duties, this duty must be balanced against other duties or modified due to equally legitimate (and conflicting) interests and principles. One example is when a patient wishes to keep information from next of kin, but the next of kin wishes to be involved, for example, to support the patient.

Family involvement can be beneficial for the patient, health service, and family members ( 10 , 11 ). Family involvement can contribute to relapse prevention and reduced hospital stays ( 12 – 14 ), secure the patient's interests when they are unable to do so, and achieve common goals and a common understanding of collaboration. Being in a close relationship with people with severe mental illness can be both meaningful and rewarding but also causes stress that contributes to poorer physical, mental, and social health to caregivers ( 15 ). Being involved in treatment can reduce the stresses family members experience ( 16 – 18 ). For health services, it is important to receive information about the patient from those who know the patient well. Simultaneously, the health workers should include next of kin and support them so that they can continue being important resources ( 3 ).

Several challenges give rise to problems when establishing family involvement in the treatment and care for people with severe mental illness. One such challenge is a lack of resources to be able to meet patients' and carers' legitimate needs in terms of time, routines, and professional knowledge. Research has demonstrated that health professionals describe such conflicts as leading to ethical challenges and dilemmas due to conflicting needs ( 8 ). The fact that health professionals describe the dilemmas as ethical may be because they do not necessarily see a difference between legal, professional, and ethical dilemmas; this lack of distinction is further complicated by the fact that these categories may be interwoven. However, to better deal with ethical challenges related to the duty of confidentiality—that is, in situations where healthcare professionals are uncertain, in doubt, or in disagreement on how to comply with the duty of confidentiality—we need nuanced knowledge on this topic. To help the whole triadic relationship to better cope and deal with these challenges, detailed knowledge and understanding of the ethical challenges at hand, seem to be important. An ethical analysis may not only serve as a basis for a better understanding of the intrinsic ethical dimensions of the duty of confidentiality, it can also give insight into how to deal with these ethical challenges.

During a preliminary literature search, we did not find any synthesis or summary of this topic. Thus, to contribute to an overview of research on ethical challenges and dilemmas related to confidentiality regarding triadic collaboration, we have analyzed and summarized the breadth and depth of the research ( 19 ) on this topic.

The aim of this scoping review is two fold:

• To identify empirical research on ethical challenges related to confidentiality when involving family and next of kin during the treatment of patients with severe mental illness.
• To review this research and make the ethical challenges more explicit and clear and therefore also more manageable.

Research question

What are the ethical challenges related to confidentiality when involving family in the treatment of patients with severe mental illness?

Search strategy

First, the research question was translated into a PICO scheme (population, intervention, comparison, and outcome; see Table 1 below). The population consisted of patients suffering from severe mental illness (SMI) and their network/family/next-of-kin. Intervention was formulated as family work/intervention/collaboration/cooperation with carers. The comparison was not specified and could be any or none. The outcome was defined as ethical challenges regarding confidentiality.

Overview of the theme, categories and subcategories from the analysis.

Table 1 population, intervention, comparison and outcome (PICO):

• Population: patients suffering from severe mental illness (SMI) and their network/family/next-of-kin.
• Intervention: family work/- intervention/- collaboration/ cooperation with carers.
• Comparison: not defined (“any or none”).
• Outcome: ethical challenges regarding confidentiality.

The second step was to build search components to develop our search strategy. We formulated three “search blocks”: (1) SMI, (2) family involvement, and (3) confidentiality (see additional file for a detailed description of our search strategy). As the next step, relevant search terms and synonyms were formulated and added to the blocks. The fourth step included selecting relevant information sources. An academic librarian (MØ) systematically searched databases covering health and psychology, including Medline (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), and Web of Science core collection (Clarivate). The Boolean operator “OR” was used within each block, while “AND” was used to combine the three blocks in the search. The initial search was performed in February 2018. In July 2018, an additional search was performed in the same databases utilizing the search term “next-of-kin”, and this search yielded one additional result ( 20 ). We performed the final update search in September 2022. There were no limits on the publication date. The search consisted of several synonyms for severe mental illness, in combination with synonyms for family relations and different aspects of the ethical challenges described earlier. We searched using both database-specific subject headings and in the fields for title, abstract, and author keywords. See Appendix 1 for full details of all searches.

After the search was executed, the results were collected into a reference management tool (Endnote). Non-research articles (theoretical papers, reviews, overviews, and commentaries), articles which were not available in English, and articles not available in full text (and/or where a detailed abstract was not available) were excluded.

Study selection

All titles and abstracts retrieved through the literature searches were screened to identify studies that potentially fulfilled the inclusion criteria for this review. To assess the articles, the authors were divided into three pairs. To ensure consistency, the first author was part of all three pairs (MHH + BM, MHH + RP, MHH + BW). If one reviewer assessed a reference as potentially relevant, the full-text article was ordered. Each full-text article was assessed independently by the authors for inclusion or exclusion. Reference lists from the retrieved full-text articles were individually reviewed and scrutinized to detect any additional articles that were not identified in the computerized literature search.

Data extraction

We extracted data from all the included studies using a data extraction sheet developed for the study. To assess the included studies, we extracted the following information: full reference, research purpose/aim, study design, theoretical perspective, context/setting (country, patient group, services/family involvement), results (ethical challenges related to confidentiality), and study limitations.

See Appendix 2 – Data extraction sheet.

Inclusion criteria

We considered all studies of ethical challenges related to confidentiality when involving family and next of kin during the treatment of patients with severe mental illness. We limited the search to studies focusing on the perspectives of patients and/or family members/next of kin and/or healthcare staff. Furthermore, criteria for inclusion were peer-reviewed primary studies or systematic reviews. There were no limitations regarding the study design. The abstract had to be available, and publication language was limited to English.

Exclusion criteria

Exclusion criteria included papers dealing with (ethical) challenges other than confidentiality and papers not focusing on SMI.

Analytical procedure

We were inspired by Graneheim and Lundman ( 21 ) descriptions of qualitative content analysis and their concepts of “manifest” (inductive approach/identify ethical and practical challenges) and “latent” (deductive approach/theoretical/ethical approach) analysis. A latent analysis approach was also a necessity in the analytical work since we found no studies where there was an explicit focus on reporting and analyzing the ethical challenges or the ethical dimension of the reported challenges.

After extensive searches, 726 publications were identified for review following removal of duplicates with EndNote. Of these, eight research papers were included in this review. In addition, we identified seven articles by manual search, of which four were included ( 8 , 22 – 24 ) ( Figure 1 ).

Study flow diagram with search strategy using PRISMA guidelines.

Ethical challenges related to confidentiality when involving family and next of kin

Based on our analyses of the selected papers, we found various types of ethical challenges related to confidentiality when involving family and next of kin during the treatment of patients with severe mental illness. We also learned that confidentiality related to different types of information resulted in different kinds of ethical challenges (e.g., information about the patient, the disease, or the treatment; information from next of kin for the healthcare professionals; or vice versa). Furthermore, the ethical challenges vary depending on stakeholder perspective (i.e., the caregiver, family, or patient perspective). In the following section, we present the results according to themes and subthemes ( Table 1 ).

The best interest of family members vs. confidentiality

Keeping family at a distance may have negative consequences for the family members themselves.

McCann et al. [( 25 ), p. 224], demonstrated that caregivers have contrasting experiences with mental health professionals. First, caregivers felt that most clinical staff were approachable and supportive. However, the study also determined that carers felt their support was undervalued by some health professionals when they were excluded from clinical considerations. Carers felt their role was not taken seriously by some health professionals. The carers' commitment to caring was affected by the way they interacted with health professionals both in first-episode psychosis service and on subsequent occasions. Cohesive, integrated, and supportive services contributed to carers' wellbeing as they struggled to provide support in light of their loved one's unpredictable behavior, anxiety, and worries as well as balancing the requirements of caregiving with other obligations.

Several of the studies found that there is poorer informal and voluntary care for the patient if the family does not receive information, support, and guidance. For example, Wilson et al. ( 24 ) observed that relatives' fighting with the mental health system leads to disempowerment as well as difficulty in accessing information, which is an argument against maintaining confidentiality. Similarly, Wainright et al. ( 26 ) highlighted that being kept out of the health and social care loop by professionals resulted in carers experiencing feelings of disempowerment, anger, loss, and isolation. Cree et al. ( 27 ) noted that:

Confidentiality was frequently raised as a barrier to carers becoming involved in both care planning and service users' care more generally. This was an emotive subject for many carers, and it could often reinforce self-blame for contributing to a service user's suffering. (ibid., p. 7)

Hence, sometimes patients' interests and the interests of relatives can both be affected at the same time by the strict application of confidentiality. Similarly, Wainwright et al. [( 26 ), p. 110] found that relatives felt they were treated as non-essentials or even as rivals. Family members reported that they had to fight with services that were vague and ambiguous. The main areas of conflict when seeking help for their family member and for themselves included information about the patient and their care; confidentiality; neglect for family members' needs and wellbeing; lack of compassion; the structure of the services; and lack of information both general and specific to the patient. Per Wainwright et al. ( 26 ), “This lack of practical advice and information falls into two broad categories: General information about statutory and non-statutory services; and resources and information about the client and their care” (ibid., p. 110).

Healthcare professionals' duty of confidentiality vs. relatives' legal rights and need for information

Some papers clearly addressed reasons and/or practices that give more weight to the need to involve relatives. For example, an argument in favor of breaking confidentiality is the importance of recognizing relatives' legal right to receive information ( 8 ). Additionally, Rapaport et al. ( 23 ) discovered that there are few policies addressing information sharing with carers. Rapaport et al. ( 23 ) also presented examples of good practice in professionals' involvement of carers that embraced carer rights and responsibilities. This implies the importance of carers' right to an assessment of their circumstances and the care context as well as strengthening the argument for appropriate information sharing between professionals and carers ( 23 ), p. 357. In line with this, Førde et al. ( 20 ) maintained that acknowledging next-of-kin's role “as informal caregivers possessing valuable knowledge, does not threaten confidentiality” (p. 7). In Marshall and Solomon's ( 28 ) study, many family members described receiving information about diagnosis and medications, but few received information about the treatment plan. Family members were satisfied when they received information from healthcare practitioners (ibid.).

Family members feeling neglected and unappreciated

Førde et al. ( 20 ) showed that family members were involved in the patient's situation. However, they reported having negative experiences as family members in their meetings with mental healthcare professionals: “Not being seen and acknowledged as important caregivers and co-sufferers were experienced as offensive and could add to their feelings of guilt” (ibid., p. 1). Importantly, lack of involvement led to family members not sharing vital patient information with healthcare professionals. Family members reported that they felt neglected, unappreciated, and dismissed ( 20 ); this finding points to the importance of informing relatives to involve them as stakeholders within the social network of the patient. Similarly, according to Gray et al. ( 22 ), being rejected by professionals resulted in carers experiencing feelings of disempowerment, anger, loss, and isolation (p. 382).

Cree et al. ( 27 ) further echoes this finding:

Whilst identifying a shared desire for involvement and confirming a potential role for carers within services, our data highlighted that many carers perceive a lack of involvement in care planning and a lack of recognition and appreciation of their role from health professionals. (ibid., p. 1)

As a result, healthcare professionals may lose the potential value of carers taking advocacy roles in situations where patients themselves are less able—or less willing—to be involved in decisions regarding care. This may lead to a hierarchy in mental health care planning “in which the relative contributions of different stakeholders are determined more by role status than by their potential expertise” (ibid., p. 8). In today's mental healthcare, where values such as respect, equality, and autonomy are strong, such a practice is ethically problematic.

Family members receiving sparse information leads to challenges and stigma

According to Wainwright et al. ( 26 ), relatives felt that the information they received was disparate and sparse, leading to them not knowing what information might be lacking or what they should look for. They did not have any idea of “the pathway that a client might take on entering services, or for themselves, they cannot imagine what information might be helpful to them or where they might seek it” (p. 111). In addition, Gray et al. ( 22 ) remarked that the interests of the patient came first: the “rights and needs of carers for information sharing were a secondary concern” (p. 381). Furthermore, relatives felt that they were seen by professionals as the enemy. Some believed that information that might be important to their own welfare was suppressed. In addition, they described their own, sometimes traumatic, emotional difficulties:

They became responsible for managing risks; had to witness and manage challenging and bizarre behavior; and suffer the erosion of the hopes that they had for the future. They remark, however, on the apparent lack of empathy and understanding that services have for these experiences. [( 26 ), p. 111]

To accommodate for and understand mental health crises, family members try to find explanations for and meaning in situations involving self-harm, violence, and detention. However, the studies determined that the mental health system does not address these problems. Family members also reported a lack of practical advice in coping with difficult behaviors, risks, financial problems, and so forth (ibid.). Family members sometimes stated that lack of acknowledgment, information, and support intensified feelings of guilt and harmed their ability to cope and care for their loved one. They explained that lack of information about the illness made it more difficult to inform others (e.g., bosses, the patient's job/school, friends, and family) about what was going on, which again may lead to stigma and lack of understanding and support (ibid.). Furthermore, Wainwright et al. ( 26 ) mentioned the problem of stigma:

Relatives believe that there is still a significant amount of stigma surrounding mental illness, despite anti-stigma campaigns. Not only is stigma aimed at service users, but relatives think that they too are stigmatized by professionals within the NHS [the healthcare system, our comment], including mental health professionals. (ibid., p. 112)

Family members are facing problems in retrieving information

In Wilson et al. ( 24 ), 56.3% of respondents reported that they faced difficulties retrieving information from mental health professionals. The main reasons for refusals to give information included lack of patient consent (46.2%) and unavailability of a team member (46.2%). Carers stated that the primary reason they felt there were problems in retrieving information was a lack of concern for their role as carer (60.5%). More than 75% of respondents were anxious about negative consequences for them or for the patient because of information being denied by mental health professionals (ibid., p. 781).

The importance of information relevant to the support role of carers

Some of the studies recorded challenges when opening up for a little less strict practice of the duty of confidentiality and more involvement of relatives. In the study by Slade et al. ( 29 ), relatives understood and respected the principle of confidentiality. Hence, there was no ethical conflict as such. Yet relatives experienced negative ethical consequences of following the principle of confidentiality:

Carers accepted the service user's right to withhold consent, but (like service users) acknowledged this might have an impact on the standard of care they can provide. They emphasized the importance of information relevant to their support role but, did not need or want to know everything about the person supported. [( 29 ), p. 151]

Wainwright et al. [( 26 ), p. 116] found that, over time, relatives learned to master the difficult situations that arise when supporting a family member who is experiencing psychosis. Families developed skills to cope with crises and prevent relapse, but they would rather be given suitable and proper information and support from a very early stage to learn these skills quickly. Indeed,

… carers spoke of the tensions that could emerge when a service user was acutely unwell and could become hostile toward the carer if they had been involved in the care planning. This became increasingly pertinent if compulsory measures had been used, particularly if these measures had been initiated by the carer, demonstrating the often competing challenges that are inherent in a carer's role. [( 27 ), p. 7]

The patient's best interest vs. the right to confidentiality

Does the duty of confidentiality overrule the need to involve family.

One core ethical challenge which was found in the selected papers is connected to healthcare professionals' respecting the duty of confidentiality regarding patient information. Most of the papers present findings in which healthcare professionals report believing that the duty of confidentiality often overrules the need to involve relatives. One argument in favor of maintaining confidentiality is that patients have a legal right to confidentiality which should be respected ( 27 ); this means that information about the patient should not be released to family members without the patient's consent. Furthermore, Slade et al. ( 29 ) observed that:

The service user interviews were dominated by one issue: the importance of patient confidentiality. All stressed how consent to disclose should be obtained before information is shared with carers. The requirement for consent was strongly linked to self-esteem, privacy, personal choice, independence, autonomy, general wellbeing and empowerment. (ibid., p. 151)

However, some studies discuss that the kinds and levels of information are important for how to deal with the choice to share the information. Slade et al. ( 29 ) make a distinction between general information, which can always be shared without consent, and personal information, which is often unknown to the carer and therefore where consent needs to be considered. Hence, the difference between general information and personal information is critical. However, Rapaport et al. ( 23 ) added a third important category, personal-sensitive, in addition to general and personal information:

… general information relates to information about mental health issues (e.g., rights, treatments, diagnoses, and services) and personal information relates to the service user's condition, treatment and care plan. The category of personal-sensitive information was identified as highly sensitive personal information relating to matters such as sexual orientation. [( 23 ), p. 363]

Moran et al. ( 30 ) deemed disclosure to be problematic, unproductive, and harmful in the doctor-patient relationship. Some of the psychiatrists in their study feared that “giving a diagnosis might harm the establishment of a positive and trusting relationship with patients” [( 30 ), p. 1373]. The study found that psychiatrists feared that diagnosis disclosure could lead to patients' losing hope for their health and consequently the danger of treatment drop-out. In addition, psychiatrists feared negative family responses toward the patient if the diagnosis was disclosed to them, worrying that family members may use the diagnosis against the patient. Finally, psychiatrists' difficulties with the task of disclosure were also connected to an emotional challenge and fear of personal safety involving the risk of provoking negative and sometimes aggressive responses toward them: “several psychiatrists anticipated hostile physical responses after sharing the diagnosis” (ibid., p. 1375). Furthermore, the psychiatrists did not address the point of psychoeducation involving family and patients and instead concentrated on supporting and caring for patients (ibid., p. 1375).

When family could provide helpful information

However, the absence of patient consent for collaboration with or involvement of family members in treatments represents an ethical dilemma related to confidentiality. Sometimes receiving information from family members presupposes sharing general information about the patient that may be perceived as sensitive by the patient, for example, that the patient is ill or receives health care if this is not already known by the family. Furthermore, even sharing general information may in some jurisdictions require consent from the patient, or this may be in a legal gray zone ( 8 , 27 , 28 , 31 ). Not involving the family members when the patients refuse, may deprive the patient of important benefits of good family involvement during severe mental illness, for example since the family often needs information and guidance to provide their best informal support for the patient. For example, in Weimand et al. ( 8 ) ethical tensions “appeared regarding confidentiality vs. what was best for the patient” (ibid., p. 292). They concluded that healthcare professionals considered confidentiality an obstacle to sharing information with relatives (ibid., p. 292). Chen et al. ( 31 ) determined that sharing information with families in mental healthcare involves competing demands between the patient's right to confidentiality and the family's wish to know. Healthcare professionals therefore “find themselves walking a fine line between adhering to confidentiality guidelines and working for the clients' best interests” (ibid., p. 1556) by involving the family.

Patient trust and alliance as a reason not to involve relatives or not to share information

Maintaining trust and building a therapeutic alliance with the patient.

Maintaining trust and building a therapeutic alliance is mentioned as a reason for not giving information to or receiving information from relatives ( 28 ). Chen's study ( 31 ) indicated that healthcare practitioners worried about losing the patient's trust, especially when the patient had difficulties building trust in the first place.

To use the information provided by families when the client–family relationship turned adversarial, case managers depended on whether the family wished to be revealed as the source of information. If the family did not give the case manager permission to do so, the case manager might employ the “coming in the back door” strategy. However, if tensions existed between the case manager and the family, the case manager tended to check with the client about the information when the family continued to contact the case manager after the client had revoked permission [( 31 ), p. 1561].

Similarly, Weimand et al. ( 8 ) found that nurses' responsibility was first and foremost to the patient: “confidentiality was tied to the trusting alliance between the nurse and patient” (p. 292). Sometimes, however, “nurses had concerns about breaking confidentiality and consequently jeopardizing the patient's trust” (ibid., p. 292). Building a therapeutic alliance is often described as putting the patient first when there are conflicts or when the patient is lacking trust, and building an alliance based on a trusting relationship is put before relatives' needs.

Chen ( 31 ) questioned whether there are good reasons for breaking confidentiality:

If a client did not have a legal guardian, case managers generally agreed that it was the client's decision that determined whether or to what extent the family could be involved in treatment, except in crisis situations, such as when the client might harm him- or herself or others. (ibid., p. 1559)

Crisis situations create ethical challenges because they raise the question of when there is a sufficient crisis and who should decide how to handle the crisis. Chen discussed the consequences of healthcare professionals having contact with and sharing information with families in the absence of client permission: “Case managers recognized that, by receiving information from families in the absence of client permission, they walked a fine line between compliance with and violation of confidentiality laws” (ibid., p. 1561). This posed an ethical dilemma when families provided helpful information for the patient's treatment.

Supporting family members

Significant focus on creating an alliance with the patient risks the danger that the family's trust in healthcare professionals is compromised and that the relationship between the patient and their family may worsen. Reasons for healthcare professionals supporting family members were:

… the context framing the nursing care, aspects of the actors, and relational concerns between them. Competing or contradictory demands were found within these premises. Two paths were identified concerning the nurses' support of relatives: seeing the relative in the shadow of the patient or as an individual person. [( 8 ), p. 285]

In Cree et al. ( 27 ), confidentiality was treated as a two-way process, meaning that carers sometimes wanted their own thoughts around care to be kept confidential. Sometimes professionals respected this, but some carers reported:

… how difficult situations had arisen which had impacted negatively on the service user/carer relationship, when they felt health professionals had breached their own confidentiality, by telling service users things that they had specifically asked them not to. These different standards or foci of confidentiality for professionals reflect the relegation of the carer's role and prioritization of the service user within services. [( 27 ), p. 7]

Many aspects regarding the doctor-patient relationship seem to pull in the direction of focusing on the patient and keeping relatives at a distance. Involving relatives creates additional challenges, even if the involvement of relatives may be best in the long run.

Clinical judgment as an argument in favor of maintaining confidentiality

According to Slade et al. ( 29 ), clinical judgment is essential to balancing conflicting ethical requirements in this field. Their study determined that clinical judgment is an argument in favor of maintaining confidentiality. The participants emphasized that “the core role of individual judgement, relationships built upon openness, knowledge and trust, and the process” (ibid., p. 150). Likewise, Moran et al. ( 30 ) stressed the importance of clinical judgment:

Their concern for the patient, and fear of the family abandoning the patient, led the psychiatrists' decision to share specific information with the family (e.g., recovery) and refrain from referring directly to the diagnosis itself—schizophrenia, as well as refraining to address the medication and potential side effects. (ibid., p. 1375)

Slade et al. ( 29 ) argument in favor of the importance of clinical judgment concentrates on the relationship (of trust) between the patient and the healthcare practitioners, whereas Moran et al. ( 30 ) focused on clinical judgments regarding the relationship between the patient and the family.

Using confidentiality as a smokescreen

Hiding behind the principle of confidentiality.

A particular type of ethical challenge emerged in the literature to describe healthcare professionals using the confidentiality principle as an argument in an inappropriate way: “Confidentiality is seen as a shield behind which services sometimes hide. This was perceived as a lazy fallback position that staff used, as opposed to attempting to work with service users and relatives to find areas of compromise and attempt to build bridges within families” [( 26 ), p. 111]. The reason for this “shield” might be that health professionals did not know how to grapple with patients' needs and families' needs, and the confidentiality principle was used as a kind of smokescreen to keep patients and relatives at a distance. Additionally, Gray et al. ( 22 ) mentioned that professionals tended to hide behind confidentiality as “confidentiality smokescreens create a type of ‘wall of silence'. This negatively impacts upon carers' involvement with services, limits the information to which carers have access and adversely impacts upon the knowledge which carers require to provide care” (ibid., p. 381). Furthermore, they stated that:

… professionals may sometimes use confidentiality issues as a reason to withhold information from carers. Professionals did not take up the challenge of acting as an intermediary to promote discussion between carers and service users concerning issues of confidentiality and appropriate information sharing. In many cases, confidentiality smokescreens, poor information sharing, and lack of dialogue resulted in professionals not identifying people as carers. (ibid., p. 381)

Weimand et al. ( 8 ) found that “although the nurses acknowledged relatives' need for, and legal right to receive, general information, they focused on patient confidentiality when arguing for difficulties regarding sharing information with relatives” (p. 292). However, the nurses in Weimand et al. ( 8 ) study were also concerned that “acting illegally would result in negative consequences for themselves and therefore felt almost unable to help” (p. 290). This is an interesting argument in favor of maintaining confidentiality.

Uncertainty, misunderstanding, or overdoing the principle of confidentiality

Hidden or ulterior motives can be described as an ethical challenge, at least if they emerge partly due to moral distress or uncertainty, such as how to balance the interests of the patient with the interests of the relatives, or how to involve the relatives when the patient has severe relational challenges. However,

Although professionals were reticent about information sharing and sometimes tended to erect confidentiality smokescreens to withhold information from carers in everyday practice, … sharing information was vital in cases involving risk management, the safety of service users and carers and for carers in crisis … Some professionals are still uncertain how far they can involve carers, even in scenarios of risk, possible harm and safety. [( 22 ), p. 383]

Another example of misunderstanding or inappropriate use of the principle of confidentiality is given by Førde et al. ( 20 ): “The NOK [next of kin, our comment] describe that confidentiality considerations are given as a reason for not talking to and involving the NOK, even when there is a high probability that the patient's competence to consent is lacking” (p. 7).

Cree et al. ( 27 ) noted the competing challenges of the carer role. Participants reported experiences where they thought that the idea of confidentiality had been misapplied to exclude carers from the patient's care; this was perceived as upsetting for those concerned and diminished the supposed importance of carers within mental health services. Cree et al. ( 27 ) understand these challenges as “lack of understanding of the nuances of confidentiality in practice, rather than a deliberate misuse” (p. 7).

In this paper, we performed a scoping review of ethical challenges related to confidentiality when involving family and next of kin during the treatment of patients with severe mental illness. With this review, we not only aim to contribute to research but also to clinical practice by means of offering insights into the core ethical challenges of confidentiality and how to deal with them.

The most important ethical challenge related to confidentiality when involving family and next of kin during the treatment of patients with severe mental illness is balancing the best interests of family members vs. the need to protect the patient's privacy. This ethical challenge is closely related to our second finding regarding balancing the patient's best interest vs. the right to confidentiality. Our findings demonstrate the importance of balancing the patient's and the family's trust at the same time. The alliance between patients and healthcare professionals is the most frequently reported reason for not involving family or not sharing information with them. Furthermore, we found that using confidentiality as a smokescreen—meaning hiding behind the principle of confidentiality—was not uncommon.

Core reflections related to themes

The duty of confidentiality and respecting the patient's autonomy.

Many of the papers in this scoping review highlighted that the duty of confidentiality is grounded in the importance of respecting the autonomy of the patient ( 8 , 29 ). Sometimes, relatives do not want to be involved in the situation of their family member for various reasons, but most often the duty of confidentiality seems to go against relatives' interests and need to take part in the life of their family member. Furthermore, how much detailed and sensitive information the relatives actually need—and what they already know—should also be considered ( 22 , 29 , 30 ).

Our review highlights that the importance of the duty of confidentiality depends on the perspective of the specific stakeholder(s) at hand. It is not only the alliance between healthcare professionals and patients that is important for the patient's health. Sometimes it is also morally right to protect the patient from relatives and to help the patient to set boundaries. This is the case in situations where relatives may be intruding in various ways or may be critical and disrespectful toward the patient. Relatives may themselves struggle with mental health problems; it may therefore be in the relatives' interest to be less involved, for instance, if they are abused by the patient and/or are exhausted due to heavy burden over time ( 9 ). However, such difficult experiences are rarely a reason for no contact or involvement. Often relatives try to understand, make meaning, and help in a situation that is difficult to understand and cope with, especially when the patient's ability to share important knowledge is limited. Therefore, trust is important when it comes to handling the duty of confidentiality. Building a trusting therapeutic relationship between the patient and health professionals is important due to the vulnerability of the patient. Based on a trusting relationship, the bonds between all stakeholders in the triad are strengthened because communication, information and participation are improved, which is what Chen et al. ( 31 ) describe as “walking a fine line”.

Alliance and confidence

According to Rapaport et al. ( 23 ), there is a general lack of confidence among health professionals in sharing information with family members. However, if family members do not receive recognition and support in their role, they will likely be less helpful to the patient, and in the worst case they may be harmful by being more worried and trying to help a seriously ill patient without understanding of how to do so properly. Therefore, too much focus on building the alliance between the patient and health professionals can only lead to relatives' distrust in health professionals, thereby weakening the relationship between patient and relatives. Furthermore, the patient may have special needs both to be understood and not to feel betrayed ( 26 ). Our analysis thus shows that a lack of communication between professionals, the patient, and the family may be particularly problematic (ibid.). Independent of how much information healthcare professionals can or are allowed to share with family members, the needs and perspectives of family members should be given sufficient weight. In the end, both the alliance between family members and the patient as well as the alliance between family members and health professionals are important ( 10 , 11 , 24 ).

During our analysis, the question emerged whether withholding information does more harm than good ( 30 ). If, for example, there are assumptions that relatives are unreasonable and have a negative impact on the patient (e.g., “bad parent”), this may lead healthcare professionals to take a detached approach to family members. Healthcare professionals need to be open and seek guidance to address and scrutinize (potential) prejudices and stigma toward relatives ( 26 ). There are, however, relatively few studies that emphasize the possible negative consequences for having no or highly limited contact with relatives (between family and health professionals and family and patient). For example, Qi et al. ( 32 ) shed light on vulnerable families concerned about the need for confidentiality, but their worry was connected to the feeling of stigma rather than to stakeholders within the family having different views and needs in relation to confidentiality. In this case, the patient's best interest seems to be compatible with the concerns of the whole family. In line with this, Førde et al. ( 20 ) maintained that acknowledging relatives' role “as informal caregivers possessing valuable knowledge, does not threaten confidentiality” (p. 7). Their findings suggested that silence can lead to mistrust and worry because the absence of patient consent raises dilemmas when families provide helpful information for the patient's treatment ( 28 , 33 ); what should healthcare professionals do with the information? Should healthcare professionals or the family themselves inform the patient that the family provided this information? Does the patient's refusal to share information about themselves with family also imply that the family is not allowed to share their information?

Weighing principles and time

This scoping review indicates that, to a large degree, overly narrow and rigid adherence to the duty of confidentiality may go against the patient's best interest in the long run. For instance, when the patient is lacking the capacity to give consent, family members—as a rule—have the right to be informed; however, this does not always take place due to strict interpretation of the law by health professionals. Using confidentiality as a smokescreen may be based on an overly narrow interpretation of the law. Ultimately, this reasoning may lead to relatives having the same right to receive information as any stranger—unless the patient is committed or lacks the capacity to consent—even though they are important informal caregivers.

On the other hand, this review also demonstrates that sometimes health professionals break confidentiality to strengthen the patient's autonomy later in the treatment process. In other words, establishing a good relationship with family members now may be helpful and promote the patient's health in the future ( 34 ). Overall, the duty of confidentiality should, like the principle of autonomy, be weighed against other principles like the patient's best interest (e.g., informal caregivers who want the best for their family member) and justice (the family's best interest should also be considered).

The value of an ethics-based approach to the concept of confidentiality

This scoping review had a specific angle when examining the challenges—both in research and clinical practice—related to confidentiality and family member involvement. From an ethics perspective within our analyses, we tried to understand and acknowledge the values and norms behind the reported challenges ( 35 ). We believe that before trying to “solve” reported challenges, it is important to understand the so-called moral constituents of the challenges. It becomes easier to develop creative strategies and balance the duty of confidentiality with other duties and principles when we have a nuanced understanding of the challenges. For example, if we better understand the moral conflict between following the duty of confidentiality related to the treatment of the patient and the need of the family to receive some information to better help the patient as carers, then we can start an inquiry into the question of whether it is possible to cater to both moral aims and to respect both at the same time. Moral conflicts or dilemmas are often presented in an abstract way and then seem unsolvable. However, if we more closely examine the concrete meaning of these principles in a specific situation, it sometimes becomes clear that respecting confidentiality does not mean that no information at all can be shared (as noted above): some information can perhaps be shared while still respecting a specific meaning of confidentiality. Or, if it appears impossible to find a balanced compromise between conflicting principles, then one can deliberate on the overarching question of what the moral limits of respecting confidentiality are. Moreover, how can we repair or deal with the possible harm that can be caused when (not) respecting confidentiality? One way of jointly developing creative means of dealing with the inherent harm that comes along with moral dilemmas within the triadic relationships is by establishing ethics reflection groups ( 35 ) or moral case deliberation ( 36 ). A more general conclusion from our scoping review is that these moral constituents of reported challenges did not receive much attention in the studies used.

Another ethics-based insight is that the negative consequences of maintaining confidentiality do not imply that the principle of confidentiality itself is morally wrong. Upholding moral principles or duties like confidentiality can cause some disadvantages; that is why they are called “principles” or “duties”. Moral principles are not meant to be ideal for every situation, and moral principles always co-exist with other principles. There are good reasons for maintaining the duty of confidentiality. When experiencing moral challenges related to confidentiality, it is important to consider its reasons and aims. Choosing not to do something simply because of the principle of confidentiality is not enough. Considering and explaining the reasons for and aims of confidentiality allows us to engage in true moral deliberation and exchange of arguments. Such deliberation can ultimately lead to the conclusion that one should perhaps breach confidentiality in a specific situation. Even if the involved stakeholders do not reach a joint consensus, research on ethics supports that after deliberation all stakeholders can better accept and understand the dissensus ( 37 , 38 ). Hence, even if ethics does not always create moral solutions, it can promote sincere dialogue and constructive relationships ( 37 , 39 ). Overall, understanding the moral constituents of moral challenges related to confidentiality and learning to deal with these will be helpful for healthcare professionals and the triadic relationship.

A final reflection that emerged from our ethical analyses of the studies is that confidentiality can—and perhaps should—be perceived as a relational concept or a relational moral principle since it is about the exchange of information between all involved stakeholders. In our scoping review, in which the triadic relationships consisted of the healthcare professional(s), the patient, and the family member(s), confidentiality played a role in six ways (i.e., from each position to the other two positions). For example, the healthcare professional can also experience moral challenges when receiving information from family members about the patient (e.g., not knowing what to do with this information or in which way they should inform the patient about the fact that they have received information from family members). Thus, dealing with moral challenges related to confidentiality in a dialogical way is even more important. Seeing confidentiality as a relational—or in this study, triadic—concept, implies that all involved stakeholders in the triadic relationship should be aware that each stakeholder can be confronted with moral challenges related to confidentiality.

Recommendations for future research and clinical practice

There is a need for more research on the topic of confidentiality. For example, we need to know more about how to keep family members' information confidential. We still do not know enough about cultural differences in preferences for respecting patients' confidentiality. Since we assume that the issue of stigma is relevant regarding confidentiality issues, we need more knowledge about how to reduce stigma and the shame following stigma.

We also need empirical research (development, innovation, evaluation, and implementation) into how we can help the different stakeholders in dealing with confidentiality and related ethical challenges. Through information about the concept and the rules, we may create a course, a module, or a specific ethics support tool ( 40 , 41 ) about the ethical challenges of confidentiality and how to deal with them, including skills training for discussing confidentiality with the triad, such as methods for ethics support like ethics reflection groups and moral case deliberation ( 35 , 39 ).

Clinical practice

More practical clarification is needed about what confidentiality does and does not entail for all perspectives within the triad, including the possible negative consequences of breaching confidentiality. The smokescreen phenomenon, or excessive application of the duty of confidentiality, can occur for various reasons such as lack of competence, experience, and routines for cooperation with relatives.

In addition, more attention is needed to distinguish between types of information and how these types do (not) relate to confidentiality. Types of information include, for instance, general information, specific information about the patient, sensitive information, and information that the family member probably already knows. The type of information shared can impact the degree to which confidentiality is broken. There will also be different degrees of negative consequences to not having contact with relatives. All these points must be balanced against each other. Contact with family members also depends on competence among staff members, routines they have, legislation, and medical record systems. Training and pilots are needed on how to handle the core dilemmas of confidentiality. Furthermore, healthcare professionals would also profit from training in dealing with contradictory principles and values, such as how to balance two conflicting values/principles; when it is allowed to break confidentiality; and, even more important, if one feels they must break confidentiality, how can they do this in a morally appropriate way (i.e., even if one cannot uphold the duty to confidentiality, can they still demonstrate care and respect to those who perhaps suffer as a result?).

Strengths and limitations

The papers we included in our study did not clearly formulate what ethical challenges are, and it was therefore not always clear for us as researchers whether to interpret challenges, problems, and dilemmas as ethical challenges or not. In response, we have chosen to interpret what was framed as “challenges”, “problems”, and “dilemmas” into “ethical challenges” and “ethical problems”. This might be a strength since naming a challenge as an ethical challenge implies that the moral dimension can be better addressed, which might lead to more creative ways of respecting or compromising the underlying moral values. However, this translation may increase the risk of misinterpretation and bias. Another limitation is that we do not cover important issues like high-risk or emergency contexts where the ethical obligations to protect the patient and others are different from a competent refusal in a non-emergency situation. Furthermore, our point concerning the protection of the patient from family does not arise from the studies reviewed but is our own observation.

This scoping review presented not only various types of ethical challenges related to confidentiality when involving the family in care for patients with severe mental illness, it also demonstrated that confidentially can be at stake in each of the six different relationships within the triad. Knowledge about the moral constituents and meaning of confidentiality challenges, both in research and in the clinical context, may facilitate a more balanced, nuanced, and creative approach to respecting the principle of confidentiality. Offering ethics support or developing a thematic ethics support tool on this subject might help in dealing with confidentiality in a better way. Overall, this scoping review revealed that the duty of confidentiality has multiple meanings and implications. Confidentiality does not always have to be a major barrier to family involvement. This insight, and its use in the future training of healthcare professionals as well as in research, may benefit patients, families, and the services.

Author contributions

All co-authors designed and planned the review approach together. MHH coordinated the scoping review and performed the search together with academic librarian MØ after consulting with all authors about the content of the PICO scheme. RP cooperated with MØ on the updated search. MHH performed the first selection of the hits (screening the abstracts based on inclusion criteria), after which all authors participated in reading equal portions of the abstracts and discussed the inclusion of those studies among each other. Next, the selected articles were evaluated in full-text by MHH while BM and RP divided the articles into equal portions for full-text review. The included articles were analysed by MHH while BM, BW, and RP contributed to the analysis scheme by adding labels that were missing. MHH was the main person responsible for the first draft of the paper, after which BM, BW, and RP participated in supplementing and revising the manuscript. All authors gave final approval of the manuscript.

Acknowledgments

We would like to thank academic librarian Marte Ødegård (MØ), Medical Library, University of Oslo Library, for valuable support in performing the searches. We are grateful to associate professor emerita Lisbet Borge (LB), VID Specialized University, for contributing at an earlier phase to this project.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

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Supplementary material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2022.960815/full#supplementary-material