Refusal of Treatment 1

Ethics Paper:

Refusal of Treatment in Mental Ill Patients

Abigail Tallon

James Madison University

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Introduction

As a patient in a mental institution, they are entitled to rights just as any mentally stable

patient is. One of these important rights is the right to receive treatment only with informed

consent or by a court order (2017, October 12). All patients, mentally ill or not, have the right to

autonomy and nurses have an ethical obligation to abide by these rights of their patient. The

biggest component of a psychiatric patient to refuse treatment is if the patient is competent or not

to accept or refuse these interventions based on informed consent (Jackson). There has been

assumptions that a psychiatric patient who refuses treatment does not know what they are saying,

which is not entirely true. A patient, for example, who has schizophrenia does not have an

impairing condition for which their ability to consent should be questioned or denied. All

psychiatric patients have certain rights and freedoms that as nurses we need to understand so we

are able to advocate for these patients like we would with any stable patient.

Background

Every nurse at some point in their career will experience some sort of ethical dilemma

that may or may not affect the way that they care for patients. I got to experience this as a student

nurse in my psychiatric clinical. Being in a psychiatric institution is completely different than

being in any ordinary hospital. There are different rules, regulations, and a different population

of patients. One day in clinical, I was in the milieu and next thing I know, there is an elderly

African American women raising her voice refusing her medication of Haldol. She repeatedly

shouted, “I know my rights. God flush this out of my system, take this and flush it out.” The

nurse surely had called security and inserted a needle into the patients shoulder. I was caught off

guard, not knowing how to react or what to do, so just stood there and observed. I later on went

up to the nurse and asked what happened with the patient and she explained to me that the patient
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had a court order for the treatment. Being a student nurse, there probably wouldn’t have been a

different way I would have responded, but if I were an RN who didn’t know the situation,

patient, or background, I most likely would have went up to the nurse and patient during the

situation in attempt to try and calm down the patient before giving the medication.

This situation caused me moral distress. The right thing to do in any normal situation is to

allow the refusal of treatment, but the court order made it impossible to pursue this action. This

situation made me feel uncomfortable and uneasy because of the distress the patient displayed. I

believe that even mentally ill patients should have the right to refuse treatment if they are not a

threat or harm to themselves or others, which in this case she was not.

Methods/ Findings

JMU established the 8 Key Questions as a system for making ethical decisions to difficult

situations that individuals face. There are eight topics that are addressed: fairness, outcomes,

responsibilities, character, liberty, empathy, authority, and rights. These eight questions are used

to evaluate ethical dilemmas of a problem and determine what the best resolution to the ethical

situation is (Madison Collaborative).

All of the eight key questions apply to this situation. Fairness is applied, because it was

not fair that the patient did not wish to have the medication but the nurse administered it anyway.

However, the shot was under court orders therefore it legally had to be given. From an outsider’s

point of view, it was not fair to the patient to be forcefully given medication. This also relates to

the liberty question in regards to freedom and autonomy. The psychiatric patient has limited

freedom, but in the end her autonomy rights were violated because she did not want the

treatment. In regards to empathy, if I truly cared about the patient involved I would have tried to
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do whatever I could to make the patient more comfortable. I would want to help the patient

understand the situation better. It seems to me that the nurse had little patience for this patient.

They didn’t really take the time to explain what was going on or why they had to give her the

medication. Authority absolutely applied, the law was the biggest factor in this situation. Due to

the fact that the patient is mentally unstable, there can be a court order that the patient is required

to be given the medication. This contradicts my ethical standing on the situation. My perspective

is that anyone should be able to refuse treatment, but this is not ideal. The law is a legitimate

authority that expects nurses to administer medication no matter how much a patient refuses it.

There are a lot of responsibilities that nurses have when caring for patients, one being to treat

patients to the best of their ability for them to get better. This applied to the situation because the

nurse has a duty to give medications to patients, even if the patient refuses. As a nurse, the

characters that I wish to have in this situation is loyalty and to be able to advocate for my

patients. Being loyal to patients creates a trusting relationship between the nurse and the patient.

However, since the nurse did not respect the patient’s wishes, she broke this trusting relationship

the patient might have had with her. It may now be hard for the patient to trust that nurse again.

Rights also played a major role in this situation. As a psychiatric patient, they have the right to

receive treatment only with informed consent or court order. The patient was under court order to

receive this medication, meaning the patient has no other choice when it comes to medication.

Lastly, the outcomes question also relates to the situation. The short-term outcome for giving the

medication to the patient is she would experience less symptoms of her psychiatric diagnosis.

The nurse also would get relief of not having to argue with the patient anymore. It was beneficial

to the patient and the nurse in the long run because after about 30 minutes the patient calmed

down and the nurse was able to focus her attention on all of her patients, not just that single one.
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Provision 4 in the ANA code of ethics helped guidance to take actions. The 4th provision

is the nurse has authority, accountability, and responsibility for the nursing practice (American

Nurse Association, Provision 4). The nurse has authority to make certain decisions for the patient

that would promote optimal care for them. In this case, it was to administer medication due to

court orders even with the refusal of the patient. It was the nurses responsibility to care for that

patient’s health and was obligated to provide optimal care.

Conclusion

This situation that I encountered was an optimal learning experience. I learned that

psychiatric patients do not have the same rights and freedoms as regular hospitalized individuals.

This was the biggest reason I experienced this ethical distress in the first place. Not knowing

about the situation made me feel uneasy as the nurse administered the medication, because the

patient was screaming that she did not want this medication in her body. As a student nurse, I

wouldn’t have done anything differently since it was not my place as a student to intervene.

Looking back, if I was that RN I would have tried to calmly explain the situation and tell her

why I was giving her the medication. I know that this is not ideal since the patient can be

uncooperative and aggressive, but in a perfect world that is the path I would have taken.

Experiencing this situation allowed me to explore my ethical standings. It also helped me

develop an understanding about different freedoms and rights psychiatric patients have because it

is important when determining care for our patients.

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References

Jackson, G. E., MD. (n.d). The Right to Refuse Treatment. Retrieved from

https://psychiatrists.org/articles/righttorefuse.htm

Mental Health America. (2017, October 12). Position Statement 21: Rights of People with

Mental Health and Substance Use Conditions. Retrieved from

http://www.mentalhealthamerica.net/positions/rights

American Nurses Association. (2016). The Code of Ethics for Nurses (Provision 4). Retrieved

from http://www.bc.edu/content/dam/files/schools/son/pdf2/ANA%20code%20of%20eth

ics.pdf

The Madison Collaborative: Ethical Reasoning in Action. (n.d). The Eight Key Questions (8KQ).

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