How do Social Policy, Law & Ethics affect the decisions made about a patient?
Introduction
The patient care incident subject to discussion involves a female patient, diagnosed to have schizophrenia, admitted to the mental health treatment ward. The admission of the patient was under Section 3 of the Mental Health Act 1983. This provision of the law provides that the admission of a patient can happen through an application for treatment made by two duly registered medical practitioners. This legal provision not only provides a guide in applications for mental health care treatment but also ensures that the application for mental health care treatment is justified based on the professional perspective of two registered health care workers specializing on mental health care. In application, the diagnosis of schizophrenia prompted the application, for the patient to receive mental health care treatment intended to prevent the patient’s condition from worsening and the commission of harm by the patient to herself or to other people. The admission of the patient for mental health care was justified.
Upon examination, the patient was overweight and subsequently found to have type 2 diabetes. This condition of the patient needed immediate and constant attention. The patient needed to undergo daily blood glucose sugar testing. However, the patient refused to cooperate in the daily tests. This problem constitutes the area of decision-making on the patient, encompassing social policy, law and ethics, since the tests are necessary but the patient refuses to cooperate.
A social policy revolving around ethical consideration is the ‘social care’ policy, introduced by the Department of Health (2007a). This applies to the decision-making for the patient since the decision-making process on the diabetes treatment of the patient should rightly consider the dignity of the patient. The social policy revolving around legal consideration is consent to treatment under the Mental Health Act 1983 and 2007 because there are certain legal considerations applying to decisions on mental health care treatment.
Social Policy
Social policy pertains to guidelines intended to ensure the achievement of human welfare objectives so that in mental health care decision-making, this pertains to decisions and the application of decisions that consider the overall human welfare of patients (Department of Health 2007a). As such, in the case of mental health care practitioners, human welfare of patients constitutes a core consideration in decisions covering the planning of the treatment of the patient, the selection of the appropriate treatment and the determination of other interventions, and the implementation of treatment.
As health care practitioners, decisions made on patient care should reflect the interest of the patient and the implementation of these decisions should find justification in the intended benefits for the patient (Department of Health 2007a). In the particular case of the female patient admitted for health care after a diagnosis of schizophrenia and subsequently found to have type 2 diabetes, the decision of health care providers involved two phases. First is the decision to monitor the blood glucose level of the patient daily together with the modification of the patient’s food diet coupled with daily exercise regimen to manage the patient’s weight (Vandiver 2007). Second is the decision on the manner of gaining the cooperation of the patient in taking the daily test for blood glucose sugar.
In the first decision, there was no argument that the Wellness Recovery Action Plan together with the alternation of the diet of the patient was the appropriate solution (Vandiver 2007). This constituted the appropriate intervention for the mental health care patient with type 2 diabetes, especially when infused into the daily routine for favourite activities by the patient such as walking around the facility and doing certain chores.
With regard to the second decision, the patient refused to cooperate in the daily test for blood glucose sugar. This test was necessary to determine changes in the condition of the patient as a means of assessing the continuation or change in the intervention plan (National Institute for Health and Clinical Excellence 2002). The extent of mental illness of the patient and her receptivity to reason determined the action made in gaining the cooperation of the patient. When the patient has been determined to be receptive to reason during the time that the tests have to be made, the health care personnel informs the patient about the test, how it will be conducted together with the purpose of the test, and the participation expected from the client. If this works then the health care personnel are able to conduct the test. This practice corresponds with the social policies of patient information and participation in the health care intervention or treatment (Department of Health 2007b). These policies ensure the patient’s welfare since the patient or in this case, the patient’s guardian is informed of the treatment to be able to provide their approval or consent to the planned intervention. In this way, the treatment is not only accomplished but also accomplished with the knowledge and agreement of the patient and/or the patient’s guardian.
However, if this does not work, then a reasonable degree of patient restraint has becomes necessary in order to finish the test. Although, this hampers the freedom of the patient, the exercise of a reasonable degree of restraint is justified by the condition of the patient and this practice is within the knowledge of the guardian of the mental health care patient. The restraint is done by enforcing sufficient pressure on patient for the duration of the test to allow the test to be made without harming the patient. This coincides with the social policy on the role of health care providers in providing competent and safe interventions or treatment to patients (Nursing and Midwifery Council 2004). Complying with this duty means that health care providers have to employ professional and tested means in order to ensure the fulfilment of the interventions planned for patients.
Social policies that ensure patient welfare have an important implication on the long-term care of the patient. Social policies serve as guide in the decision-making and decision implementation of health care personnel on the daily intervention or treatment planned for the patient directed towards the long-term goal of making the patient well to take up familial, employment and other social roles before the onset of the mental health care condition of the patient (Department of Health 2007a). Long-term intervention for the patient involves the prevention of the worsening and managing the type 2 diabetes of the patient infused with the treatment for the mental health care condition of the patient.
Law
The law relevant to the patient’s situation is the Mental Health Act 1983 and the Mental Health Act 2007, with the latter introducing amendments to the earlier statute. The Mental Health Act 1983 was enacted to provide guidance in the practice of mental health care, particularly the policies on the application for treatment, assessment or diagnosis of patients, guardianships and other related policies. The statute also serves as a regulation for the practices of health care professionals involved in mental health care. The legislation is divided into ten parts encompassing these subjects: 1) scope of application of the law; 2) guidelines for compulsory admission to mental health care facilities; 3) policies on mental health care patients involved in criminal cases; 4) provision of consent to interventions or treatment; 5) role of the mental health review tribunal; 6) policies in case patients are removed and returned within the UK; 7) guidelines on the management of the properties and affairs of mental health care patients; 8) support functions of the local authorities together with the Secretary of State; 9) policies on offences; and 10) supplementary provisions. (Department of Health 2007c) These parts indicate that the Mental Health Act 1983 provides guidance on mental health care practice to prevent abusive or illegal actions by health care professionals and protection to mental health care patients by providing for remedies and redress bodies intended to address complaints by patients and clients.
However, since the Mental Health Act 1983 revolved mostly around the application for mental health care and assessment of patients, the Mental Health Act 2007 was enacted to stress on the other aspects of mental health care. This law involves five substantive changes. First is the recognition of the equal status of civil partners and spouses as nearest relatives for purposes of guardianship. Second is the increase in the maximum punishment for the neglect or unacceptable treatment of mental health care patients to five years instead of two years. Third is the consideration of court orders for the detention of offenders with mental disorder as having no limit so that this applies until that the appropriate bodies have determined it safe to lift the detention order. Fourth is the prerogative of 16 and 17 year old individuals to refuse admission in mental health care facilities for treatment even with parental consent to prevent the detention of individuals without the protection of the formal application policies contained in the law. Fifth covers changes in the eligible parities playing the role of independent mental capacity advocates to enhance the welfare of patients. (Department of Health 2007d)These amendments further strengthened the protective aspect of the earlier statute.
These laws applied in the case of the patient with schizophrenia discussed earlier. The admission of the patient was in accordance with the rules on application for treatment. It was through the decision of two professional and registered mental health care practitioners that the patient was admitted for treatment in the facility. The application for treatment was based on the recognition that the lack of immediate treatment would worsen the condition of the patient and increase the risk of harm to the patient and to other people. The provision on consent for treatment also applied to the given case because the patient, when perceived to be receptive to reason and explanations, was informed of the purpose and expected patient participation in the daily blood tests for diabetes. The patient’s guardian was also informed of the treatment and interventions covering the daily interventions and the long-term impact of the treatment.
Based on the decisions made by the health care personnel on the intervention and treatment of the client, it appears that the provisions of these laws were applied appropriately. Formal application policies were implemented. The provisions on patient consent were also applied. These provisions explain that there are instances such as surgery likely to affect the brain or its functions, as treatment, requires the consent of the patient or the patient’s guardian. Treatment plans also need the consent of the patient. Although, the patient refused to undergo the daily tests for blood glucose sugar, the patient was always informed of the daily test when the patient is perceived to be receptive to reason and the patient’s guardian was informed of the intervention plan.
While the approach of considering laws in mental health care decision-making offers advantages such as the provision of guidelines to prevent negligence cases from being filed against mental health care professionals and protect patients, the application of these laws depend largely on the judgment of health care professionals given varying circumstances so that experience and expertise are important factors in addition to knowledge of the law.
Ethics
Ethics comprise values, norms or practices derived from considerations of right and wrong. This means that ethical issues in mental health care cover problems involving the consideration of the right and wrong perception, attitudes or actions. The ethical issue arising in the case of the female patient diagnosed with schizophrenia revolves around the ‘social care’ policy developed by the Department of Health (2007a). This policy provides that mental health care professionals should make decisions concerning patients with the dignity and privacy of the patient. The policy seems straightforward but application could be complex or even problematic. Respect for the dignity and privacy of clients (Department of Health 2007b) becomes an ethical issue in the case of mental health care patients because of the limited capability of these patients to decide or act for themselves. Mental health care constitutes a special area of concern for the application of this policy. The ‘social care’ policy was based on the assumption that patients have an interest in their treatment plans and capable of making judgments and giving consent to these treatment plans (Department of Health 2007a). However, in the case of mental health care, consciousness of their health care interest and judgment on treatment plans are not always present. In these cases, protecting the dignity and privacy of patients lies in the rational practice of health care professionals given varying circumstances.
Respecting the dignity of mental health care patients became an issue in the case of the patient diagnosed with schizophrenia because of the refusal of the patient to cooperate in the daily tests for her blood glucose sugar as part of the intervention for her type 2 diabetes. In normal cases of patients with diabetes, the refusal of the patient to participate in the daily tests could have been eased by informing the patient (Royal College of Nursing 2005) about the purpose of the test and how the test would go. Gaining the consent of the patient through informed patient decision-making (Robbins 2004), would ease the succeeding tests. However, in the case of mental health disorder co-occurring in patients in type 2 diabetes, consent is not always achievable. Health care professionals need to employ interventions such as physical restraint to implement treatment. In this instance, the ethical issue of the intervention considered as reasonable emerges. The extent of physical restraint, the manner of applying restraint, and the duration of the restraint are issues concerning right and wrong. The physical restraint should be within what is commonly considered acceptable and reasonable. Although this issue did not arise in the case because of the implementation of the extent of physical restraint deemed by the health care personnel and even the guardian as acceptable, this could give rise to questions of the appropriateness of physical restraint in other circumstances when considered in the context of the social policy of respecting the dignity and privacy of respondents. The implementation of excessive physical force or not informing the patient or guardian about the plan involves violations of the dignity of mental health care patients. The conduct of tests in a manner that violates the privacy of mental health care patients also goes against ethical norms of practice.
The consideration of ethics in mental health care practice has important implications on the welfare and long-term outcomes for the patient. First, ethical considerations in decision-making processes of mental health care professionals results to intervention or treatment plans that considers acceptable practice that respects the dignity and privacy of patients. In this way, health care professionals are not placed in question regarding their decisions and actions while patients do not experience treatments in violation of their dignity and privacy. This then prevents negligence and malpractice. Second, ethical practice in mental health care provides a common standard for practice so that mental health care professionals have a guide in dealing with practical issues but standards are flexible enough to accommodate specific situations. Since ethical practice relies on the judgment of health care professionals, enhancement of knowledge and experience becomes important.
Discussion
Based on the consideration of social policy, legal and ethical issues emerging in the particular case, these have influenced a number of realizations with regard to patient care. One, patient care is multi-dimensional because this involves social, legal and ethical aspects (Pilgrims & Rogers 2005). From the perspective of health care providers, caring for patients is not only limited to the treatment of the condition of the patient but also the consideration of the overall welfare of the patient. Health care has transcended the mere consideration of the appropriate intervention or treatment to the consideration of the appropriate means of implementing intervention and treatment plans based on the principles of informed patient care, patient and health care provider collaboration or partnership, and social care. Knowledge and expertise in health care provision should find application not only on treatment but also on treatment implementation that ensures the overall welfare and respects the dignity and privacy of patients. Another, health care professionals have to be prepared to take on multi-faceted roles from merely providers of care to providers of social care (Haber & Billings 1995). Although, health care professionals often collaborate with social workers in dealing with patients, health care personnel also need to gain practical knowledge on social care and ethical practice.
In dealing with patients under a similar circumstance as the patient with schizophrenia and type 2 diabetes, applying social care and ethical practice involves an understanding of the mental condition of the patient. This is necessary to determine the situations when patient information works and instances when other interventions are appropriate together with the effective manner of providing information and applying interventions such as physical restraint. To employ ethical practice, biases or stereotyping of patients should be minimized or even prevented to ensure objective assessments of the specific condition and symptoms of patients to support decision-making on interventions or treatments. In the specific case of mental condition co-occurring with type 2 diabetes, care should also be coordinated in order to integrate interventions for the diabetes with the treatment for mental condition.
The change in perspective finds support in person centred care, which provides that health care provision should consider standards of care and consider the specific circumstances of the patient to achieve effective interventions or treatments (Fulford, Ersser & Hope 1996). This also finds close links to the evolving responsibility of health care professionals in providing social care and practicing ethical health care (Haber & Billings 1995; Pilgrims & Rogers 2005). Instead of just focusing on the science and technicalities of health care provision, effective health care delivery should involve factors affecting patients such as social and ethical issues to deliver holistic health care.
Conclusion
Health care delivery has evolved into a multi-faceted application. As such, consideration of social policies, laws, and ethics in health care delivery have become important in decision-making. Social policies applicable to the described patient case include obtaining the consent of clients or their guardians as a way of respecting their dignity and privacy and the making of justifiable objective decisions by health care providers in certain circumstances. Social policies describe the social considerations necessary in the health care practice. Law applicable to the patient described is the Mental Health Act 1983 and 2007 that provide guidelines for practice and accord protection to patients. Ethical issues arising in the case presented revolves around the decision on the means of ensuring the application of necessary and planned treatment that are appropriate and reasonable. Consideration of these factors ensures that health care delivery becomes patient-centred and holistic.
References
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Department of Health (2007b) About the Dignity in care campaign, Department of Health, available at http://www.dh.gov.uk/en/Policyandguidance/SocialCare/Socialcarereform/Dignityincare/DH_065407
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