Week 9 - Mental Illness and Ethics

BSN502 Health Law and Ethics in the UAE
Mental Illness and Ethics
Semester 1: AY 2023-2024
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Lecture Outcomes
By the completion of this lecture, tutorials, and self-

directed learning the student is expected to be able:
 Define mental health and mental illness.
 Discuss stigma, its impact on people with mental illness

and strategies that may be used to reduce the impact of
stigmatization.
 Identify facts/myths about mental illness.
 Discus restraints and legal and ethical issues regarding

the restraints.
Original material supplied by Health Protection Scotland. Responsibility for the editing and use of these materials lies with the individual and not Health Protection Scotland or Healthcare A2Z.
© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org fchs.ac.ae
Lecture Outcomes
 Discuss the Tarasoff ruling of “duty to warn”.
 Describe ethical issues relevant to mental

health nursing.
 Describe the rights of people who have a

mental illness.
 Identify behaviors in which malpractice action

could be taken.
Background
•1 in every 8 people in the world live with a mental disorder
•In 2019, 1 in every 8 people, or 970 million people around

the world were living with a mental disorder; anxiety and
depressive disorders being the most common
•In 2020, there was a 26% and 28% increase respectively for
anxiety and major depressive disorders, due to COVID.
•Most people do not have access to effective care (World

Health Organisation [WHO], 2022).
Mental Illness
What is Mental Illness?
Mental health - relatively emotionally stable; functioning
within acceptable cultural expectations.
Mental health problem - signs & symptoms of illness

present, but do not meet specified criteria for disorder
(most will experience these at times)
Mental disorder - disorder of thought or mood that

significantly impairs judgment, behavior, the capacity to
recognize reality, or the ability to cope with ordinary
demands of life (Stein, Palk,& Kendler, 2021).
© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

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Original material supplied by Health Protection Scotland. Responsibility for the editing and use of these materials lies with the individual and not Hea lth Protection Scotland or Healthcare A2Z.
fchs.ac.ae
Mental Illness
What is Mental Illness?
Mental illness - all diagnosable mental disorders
In common usage :
• a mental disorder is what you are diagnosed with.
• a mental illness is when that disorder actually interferes

with your life.
• conditions involving changes in emotion, thinking or

behavior. It may be a combination of these (World
Health Organisation [WHO], 2022).

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Mental Illness
 People with mental illness are among

the most highly stigmatized and
disadvantaged throughout the world
(WHO, 2022).
 Stigma can be defined as a mark of shame,

disgrace or disapproval that result in an individual
being rejected by others (Subu et al, 2021)
© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org 8 fchs.ac.ae
 Stigma is a characteristic that
distinguishes a person as different from
others; that he/she is imperfect in some
way.
 It is applied by a dominant group of

people to gain power over an individual or
group.

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Original material supplied by Health Protection Scotland. Responsibility for the editing and use of these materials lies with the individual and not Hea lthProtection Scotland or Healthcare A2Z.
fchs.ac.ae
Impact of Stigma on Mentally Ill
People with mental illness :

 are often ignored or treated as though
they are less valuable human beings
 viewed as weak, incapable, stupid,

dangerous, or responsible for their own condition.
 may experience shame, embarrassment, and social

isolation
 often have difficulty with education, housing, employment,

and health care coverage.

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Stigma harms people with mental illness in three

ways:
1-Label avoidance
 not fully adhering to treatment regimens once
begun,
 do not want to be labeled a "mental patient" .
 Or suffer the prejudice and discrimination that
the label entails.
2-Blocked life Opportunities:

 problems to obtain good jobs or find suitable housing
3- Self-stigma
 Internalize stigma ideas and believe that they are less
valued
 stereotypes: "That's right; I am weak and unable to care

for myself!"
 negative emotional reactions; shame, low self-esteem,

and diminished self-efficacy
Rights of People with Mental Health Disorders
 In the UAE there are 2 Federal Laws that are related to
people with mental illnesses and disorders.
 Federal Law (no.28) concerns the detention and treatment

of people with mental disorders -governs the custody and
treatment of mentally ill people.
 There is a Federal Laws (no.29) of 1981 that protects the

rights of people with mental disorders and prohibits
aggression against them

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Rights of People with Mental Health Disorders
The WHO Mental Health Report (2001), the United States
Mental Health Bill of Rights (1997), and the Australian
Mental Health Statement of Rights and Responsibilities
(1995) include statements of key rights such as:
1. Right to appropriate treatment in a setting that is least

restrictive to personal freedom.
2. Right to participate in and receive an explanation of care

and treatment.

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Rights of People with Mental Health Disorders cont.
3. Right to refuse treatment except in an emergency.
4. Right to freedom from restraint or seclusion except
in emergency situation.
5. Right to a humane treatment environment that
provides protection from harm and privacy .
6. Right of access to telephone, mail, visitors, unless
deemed inappropriate for treatment

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Top 10 Myths About Mental Disorders
1. Mental health problems are uncommon
2. Caused by the person suffering from them
3. Purely biological or genetic in nature
4. Often life-long and difficult to treat
5. Psychotherapy takes forever and involves

discussing childhood issues

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Top 10 Myths About Mental Disorders
6. If I can’t handle my mental health problems, I’m weak
7. If I admit I have problems, everyone will think I’m crazy, and I’l
be sick for along time
8. Being suicidal means I’m crazy
9. Best treated by the family doctor
10. Mental health professionals make loads of money

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Legal & Ethical aspects of restraints in mental health

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Restraints
Royal College of Nursing:
Restraint:
 "The intentional restriction of a person’s
voluntary movement or behavior"
 stopping a person doing something they appear to

want to do

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Restraints
• Mental Capacity Act 2005
“The Mental Capacity Act 2005 describes restraint

as: the use or threat of force to help do an act
which the person resists, or the restriction of the
person’s liberty of movement, whether or not
they resist. Restraint may only be used where it
is necessary to protect the person from harm and
is proportionate to the risk of harm. “

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Restraints
Mental Welfare Commission:
“In its broadest sense, restraint is taking place when the

planned or unplanned, conscious or unconscious
actions of care staff prevent a resident or patient from
doing what he or she wishes to do and as a result
places limits on his or her freedom.”

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Restraints
Omissions and Negligence
 “If we were to physically restrain someone that would be an

act - we have taken an action. However, if we were not to
restrain someone when we should have done....and that
failure to 'assist' or 'go to their rescue' led to an injury
that could not have occurred had the act of restraint taken
place,
 Then we have possibly 'omitted' to do something that we

should have done. In short we (or indeed the employer)
may be cited for negligence.”

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Methods of restraint
1- Physical restraint
 involves one or more members of staff
holding the person, moving the person,
or blocking their movement to stop them
leaving.
2- Mechanical restraint
 involves the use of equipment:
 special mittens in intensive care; heavy table or belt;
bedrails
 keys, baffle locks and keypads to control freedom of

movement.
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Methods of restraint
3- Technological surveillance
 tagging, closed circuit television, or door alarms
4- Chemical restraint
 involves using medication to restrain.
 prescribed medication including that to be used
 over-the-counter medication, or illegal drugs.
5- Psychological restraint: include constantly telling the

person not to do something, or that doing what they want
to do is not allowed, or is too dangerous.

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Restraints
So …
Legally and Ethically, what kind of force could be
appropriate to use if we must safeguard a patient
from harm?

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Restraints
 Physical Force should be the absolute last resort

in managing conflict.
 Physical force should only be used for its lawful

purpose
 Physical force should never be used

 Revenge;
 Retaliation;
 Retribution;
 Teaching people a lesson
 Compliance with an Instruction
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Restraints
What is Reasonable ?
The requirement to use force which is reasonable in the

circumstances involves two issues:
i. Was the force used necessary (or honestly believed to
be necessary) to prevent the crime or effect the arrest?
i. Was the force used proportionate to the evil to be

avoided?.

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Restraints
Mental Health Code of Practice 1983 (rev. 2008)
Managing aggressive behaviour by using physical

restraint should be done only as a last resort
and never as a matter of course. It should be
used in an emergency when there seems to be
a real possibility that harm would occur if no
intervention is made.

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Restraints
Aspects of Necessity
1. Is the Threat Imminent?
2. There is a duty to avoid conflict – To disengage

and to make some physical withdrawal.
3. Freedom of Movement.
4. The Pre-emptive strike.
5. Necessity & Law Enforcement.

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Restraints
So….
If it has become NECESSARY to use
force.....
How much force will it be appropriate to

use?

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Restraints
The Proportionality Rule

"what is reasonably proportionate to the amount of harm
likely to be suffered by the defendant or likely to result if
the forcible intervention is not made?”
“the reaction must be in proportion to the harm which

is threatened”
“Force Must Parallel Danger”

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Restraints
Rights Regarding Seclusion and Restraint

Legally, behavioral restraint and seclusion are authorized as an
intervention when:
 The particular behavior is physically harmful to the client or a
3rd party
 The disruptive behavior presents a danger to the facility
 Alternative or less restrictive measures are insufficient

in protecting the client & others from harm
 When a decrease in sensory over stimulation is needed

Duty to Warn vs.
Confidentiality Issue
 In the United States, failure to warn a potential victim of
harm is a form of malpractice. In 1976, the landmark case
of Tarasoff vs. Regents of the University of California
(Johnstone 2004) changed the relationship between
health care professional and public authorities.
 The duty to warn takes precedence over the duty to protect

patient’s confidentiality.

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Exception of confidentiality: “Duty to Warn
SO:
When a therapist is reasonably certain that a patient is going
to harm someone, the therapist has the responsibility to
breach the confidentiality of the relationship and warn or
protect the potential victim.
Gravely Disabled
 The condition of a person who is unable to provide for his
own basic physical needs
 essential food, clothing, medical care, shelter,
 unable to survive safely in freedom or protect himself
from serious harm.
 The term also includes unconscious or has impaired

judgment
 Cannot make a rational decision with respect to his
need for treatment.
Cause - serious mental illness or substance abuse, alcohol

incapacitation
Original materi
or Healthcare A2Z.
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10/11/2023al supplied by Health Protection Scotland. Responsibility for the editing and use of these materials lies with the individual and not Hea4lth5Protection Scotland
Issues with Right to Refuse Treatment
 Patients refusing to take psychotropic drugs.
 The medical consequences include committed to hospital

involuntarily, discharge home, or, a legal competency
hearing.
 Where there is danger to the patient or others, it is

appropriate to forcibly medicate patient and it may be
supported in some countries by law.

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Issues of the Right to the Least Restrictive Treatment
Alternative
 Mentally ill patients have the right to receive the least
restrictive means of treatment needed to get the desired
effect.
 Mental “restrictiveness” of therapy considers the severity

of the illness and may be described in terms of setting
and type of therapy.

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Alternative
Setting
 Treated on an outpatient basis on appointment
 In day hospitals where they undergo therapy

during the day but go home at night
 Voluntary or involuntary hospitalization

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Alternative
Type of Therapy:
• Verbal rehabilitative techniques
• Behavioural techniques
• Chemical interventions
• Seclusion
• Mechanical restraints
• Electroconvulsive therapy

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Confidentiality and Privacy Issues
 Patients’ records and communications must be protected.
 Privileged communication- when

psychiatrists, psychologists, attorneys, religious figures,
and nurses
 May refuse to reveal information about and

communications with patients.
 The right to patient privacy is exempt in a civil or criminal

case.
 The medical record may be used as evidence.
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Informed Consent Issues
 Psychosis does not necessarily mean that a person

is unable to consent to treatment
 Many psychotic patients are capable of giving

informed consent.
 For patients not able to consent and for all minors,

informed consent should be obtained from a
substitute decision maker.

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Informed Consent Issue
 Conditions under which treatment can be performed

without obtaining informed consent (Townsend 2002):
 when the patient is mentally incompetent to make a

decision which is necessary to preserve life or avoid
serious harm
 when refusing treatment endangers the life of others
 in an emergency when the patient is in no condition to

exercise judgment
Informed Consent Issue
 if the patient is a child
 If the patient is severely mentally ill and does not

possess the cognitive ability to give consent, a
relative or legal guardian may be asked to do so.
Malpractice Issues in mental Health illness
Townsend (2002) suggests nurses be aware of the kinds of

professional behaviors that might place them at risk for a
malpractice charge, such as :
 Breach of confidentiality
 Defamation of character
 Invasion of privacy
 Assault and battery
 False imprisonment

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Common areas of liability in mental illness services
 Sexual contact with a patient
 Preventing patient suicide
 Medication errors
 Problems related to Electro Convulsive Therapy
 Breach of confidentiality
 Failure to refer a patient
 Failure to obtain informed consent
 Failure to report abuse
Nursing Actions to Avoid Liability
 Practice within the scope of nursing practice and

code of conduct
 Observe hospital policy
 Ensure practice is up to established standards
 Put the patient’s rights and welfare first
 Develop and maintain a good relationship with the
patient and family
 Develop psychosocial communication skills

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Let’s Review
1. Using the mittens in the Intensive Care Units, to restrict the

patients’ movement, to stop them from getting out of their
beds, and to control their freedom, is an examples of:
a. Chemical restraint.
b. Psychological restraint.
c. Mechanical restraint.
d. Technological restraint.
Let’s Review
2. The nurses’ respectful interactions with patients with mental

illness is best identified by all of the following actions, EXCEPT
_____
a. devalue them for who they are;

b. respect the patients as they are worthy;
c. listen and take seriously what the patients say;
d. support the actions that promote the patient’s wellbeing.

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BSN502 Health Law and Ethics in the UAE

Mental Illness and Ethics

By the completion of this lecture, tutorials, and self-

 Define mental health and mental illness.

 Discuss stigma, its impact on people with mental illness

 Identify facts/myths about mental illness.

 Discus restraints and legal and ethical issues regarding

 Discuss the Tarasoff ruling of “duty to warn”.

 Describe ethical issues relevant to mental

 Describe the rights of people who have a

 Identify behaviors in which malpractice action

•In 2019, 1 in every 8 people, or 970 million people around

•Most people do not have access to effective care (World

Mental health problem - signs & symptoms of illness

Mental disorder - disorder of thought or mood that

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

• a mental illness is when that disorder actually interferes

• conditions involving changes in emotion, thinking or

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

 People with mental illness are among

 Stigma can be defined as a mark of shame,

 It is applied by a dominant group of

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

People with mental illness :

 viewed as weak, incapable, stupid,

 may experience shame, embarrassment, and social

 often have difficulty with education, housing, employment,

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

Stigma harms people with mental illness in three

2-Blocked life Opportunities:

 stereotypes: "That's right; I am weak and unable to care

 negative emotional reactions; shame, low self-esteem,

 Federal Law (no.28) concerns the detention and treatment

 There is a Federal Laws (no.29) of 1981 that protects the

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

1. Right to appropriate treatment in a setting that is least

2. Right to participate in and receive an explanation of care

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

5. Psychotherapy takes forever and involves

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

Royal College of Nursing:

 stopping a person doing something they appear to

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

• Mental Capacity Act 2005

“The Mental Capacity Act 2005 describes restraint

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

Mental Welfare Commission:

“In its broadest sense, restraint is taking place when the

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

Omissions and Negligence

 “If we were to physically restrain someone that would be an

 Then we have possibly 'omitted' to do something that we

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

 keys, baffle locks and keypads to control freedom of

5- Psychological restraint: include constantly telling the

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

© 2006, original content developed by Healthcare A2Z, www.healthcareA2Z.org

 Physical Force should be the absolute last resort

 Physical force should only be used for its lawful

 Physical force should never be used