Commonly, nurses think that they know what is best for their clients, often imposing their own methods for care and treatment decisions. This behavior, referred to as paternalism, may occur in the psychiatric clinical setting where clients exhibit clinical symptoms of confusion, depression, or anxiety or when clients are unable to communicate their needs because of communication disorders or mental retardation. The nurse may fail to recognize an ethical dilemma as a result of lack of training in ethics or lack of available resources to describe ethical issues (Box 5-2 lists examples of nursing resources on ethics). The nurse may also fail to act or intervene when an ethical dilemma is identified. Failure to act can violate the Code of Ethics for Nurses With Interpretive Statements (ANA, 1985). This action could constitute a breach of standard of care and violate a state’s Nurse Practice Act. The nurse may be subject to liability if the breach of care results in any harm or injury to the client.

Chally and Loriz (1998) developed a six-step ethical decision-making model for nurses to use when confronted with ethical dilemmas or moral problems that involve two or more mutually exclusive, morally correct courses of action. During the implementation of this model, the nurse must respect the individuality of all clients, protect clients from harm, treat all clients equally, and evaluate the result of full disclosure regarding treatment. The following is an example of the application of the six steps of Chally and Loriz’s model during an ethical dilemma:

Concentration on pain management—considered the fifth vital sign—and comfort measures should be an ethical responsibility of all clinician–client relationships. Psychiatric–mental health nurses provide care for clients who verbalize symptoms of pain, especially those clients who present with a comorbid medical condition, terminal illness, or clinical symptoms of a somatoform disorder (see discussion in Chapter 20). Individuals with a history of substance abuse, especially narcotics, may also present with complaints of pain. The nurse may find it difficult to determine whether such clients are indeed experiencing pain or are attempting to obtain their addictive drugs of choice.

In 1995, the Journal of the American Medical Association published a study in which 4,300 terminally ill clients were followed up on until their deaths. According to the data, 50% of the clients’ physicians claimed that they had no indication of the clients’ end-of-life wishes. In the same study, 2,300 terminally ill clients were assigned a registered nurse who intervened weekly with each client, the client’s physician, and the client’s family. Again, 50% of the physicians claimed that they were unaware of their clients’ wishes regarding pain management and end-of-life care. More than 50% of the family members stated that their loved ones suffered moderate to severe pain in the last 3 days of life (Dunegan, 2000; issues related to end-of-life care are addressed in Chapter 7).

Although rating tools to assess pain intensity and guidelines for pain management are available, some nurses still have difficulty participating in the pain
management of their assigned clients. In the past, nurses were overly cautious because most available pain medication was highly addictive. Nurses were faced with ethical dilemmas, that is, administering pain medication but not wanting to promote substance abuse by clients. Now, more than 30 states have established clinician guidelines for pain management. The federal and state licensing boards meet regularly with representatives from the Drug Enforcement Agency (DEA) to review the actions of clinicians who prescribe pain medication. In addition, the federal government has mandated that any hospital receiving federal funding must make pain management a priority. Pain must be rated and relieved, with the effectiveness evaluated for every client. Clinicians who refuse to address the pain and suffering of clients may be sanctioned. Box 5-3 lists examples of situations in the psychiatric setting that may pose ethical dilemmas associated with pain management.

Nurses in every specialty care for clients and/or families who have or are at risk for the development of various genetic disorders, such as Huntington’s disease, cystic fibrosis, or muscular dystrophy, and common diseases such as heart disease and diabetes that are caused by altered genes. A genetic marker also has been identified for eating disorders. Research scientists continue to search for genetic markers related to various psychiatric disorders. Research also focuses on the development of second- and third-generation psychotropic medications with fewer adverse effects to alleviate clinical symptoms of psychiatric disorders.

Nurses must become knowledgeable about genetics and the issues surrounding this topic. Genetic testing, the laboratory analysis of cells for gene products (eg, proteins, enzymes, metabolites) or DNA analysis (eg, chromosomal analysis), promises early identification of diseases and cure. Genetic testing also is making advances in prenatal predictive testing. Genetic testing may allow providers to discover a person’s genetic predisposition to a given disease; to predict the onset, extent, and severity of the disease; and to determine treatment options. Caring for clients who undergo genetic testing presents ethical dilemmas because it tests our knowledge as well as our conscience. A potential for coercion exists, for example, when grown children urge parents to undergo genetic testing for a disease known to determine their own risk (Sanders, 2001b; Silberstein, 2003; Spahis, 2002).

Genetics or biotechnology is not unique to the 21st century. Gregor Mendel, a botanist, is considered to be the founder of genetics in 1865. The X and Y chromosomes were identified in 1905. In 1941, the term genetic engineering was coined. In 1982, insulin was genetically engineered; in 1989, a gene for cystic fibrosis was found. Since then, a series of events occurred that led President George W. Bush to announce the funding of embryonic stem-cell research on August 9, 2001 (Sanders, 2001b).

Nurses can participate in clinical research, including research associated with psychiatric–mental health. Karigan (2001) identifies three ethical dilemmas that the nurse may confront during participation in clinical research if he or she is not familiar with research protocol. The first ethical dilemma addresses the issue of informed consent (the client’s right of self-decision). Violations of the ethical principles of
informed consent are committed when there is no consent; when a consenting client is not fully informed of the details of the research study, including expected outcomes, benefits, or risks; or when the client is not continually informed of study changes or results.

A second ethical dilemma may involve documentation of research protocols. Nurses need to know the outline of the protocol and how to locate specific information related to it. The protocol outline should be kept in a designated location, readily available so that nurses can refer to any guidelines that pertain to their roles. If the nurse is unable to locate the protocol and is given an order to administer an investigational drug or provide a specific treatment, the nurse may refuse the physician’s order until consultation with appropriate resources—such as a pharmacist—occurs.

The third ethical dilemma may involve the client’s right to full disclosure about the research study or trial. If the client makes any statements that indicate misunderstanding or lack of understanding about research protocol, or if the client indicates perceived coercion by others, the nurse is responsible for alerting the program research investigator of such statements.