In this section we will spend some time revising the ethical theories that are of interest to people working with families who are affected by mental health problems. We will explore the concepts of ethical decision making and use a ethical decision making framework and apply it to a number ethical issues concerning families.

After engagement with these eLearning materials you:

  1. will have an understanding of the importance of the need to study ethics.
  2. will have an understanding of ethical theory.
  3. will have an understanding of the four main ethical principles.
  4. are be able to use ethical decision making frameworks to work through a number of ethical dilemmas which might emerge when working with the family.

Why do we need to study ethics?

According to Wheeler (2012 p. 155), Nurses need to have a clear understanding of the ethical principles and theories and the moral codes and values that they are using to make caring decisions. While there are many policies and procedures that guide nurses in making day to day decisions about the care they provide, often we encounter situations that do not 'fit' within predetermined frameworks or they cause us to question our own personal values and beliefs about the nature of health care. This is especially relevant in the area of mental health when we often encounter vulnerable people in a variety of settings. When working with families, ethical issues may emerge in a variety of contexts that will be discussed later in this section.

Robertson & Walter (2014 p.4) describe a taxonomy of Normative Theories in Psychiatric Ethics which are divided into three domains or approaches:

  1. Instrumental approaches
  2. Reflective approaches
  3. Integrative approaches

These are detailed in the table below:

Approach Normative Theory
INSTRUMENTAL APPROACHES (i) Utilitarian ethics (ii) The ethics of duty (iii) The four principles (iv) Casuistry (v) Common morality theory.
REFLECTIVE APPROACHES (i) Virtue ethics (ii) The ethics of care (iii) The ethics of care.
INTEGRATIVE APPROACHES (i) 'political' ethics and the Rawlsian approach to justice in mental health (ii) Postmodern ethics or anti-modern ethics.

According to Robertson & Walter (2014 p 4-5) instrumental approaches apply a particular methodology to a problem which helps arrive a decision, reflective approaches help us to engage in a process of reflection and integrative approaches examine particular theoretical ideas in the context of specific aspects of clinical practice for example resource allocation.

Visit the UK Central Ethics Network website and read more about the ethical theories and frameworks that they describe.

According to Gallagher (2013) the four principle approach is one of the most common ethical perspectives on health care ethics. The four principles are:

  1. Respect for autonomy
  2. Non-Maleficence
  3. Beneficence
  4. Justice

The four ethical perspectives are desribed using a case study at the UK Central Ethics Network.

Given the four ethical principles listed above, can you think of any instances when these principles might be compromised when working with a family affected by mental health problems?

Codes of Practice

Many health and other professionals which are governed by regulatory bodies are guided by codes of practice which generally stipulate basic rules of ethical conduct. The codes are often used to interpret good and bad practice and are important documents that all mental health professionals should be aware of.

Locate the code of conduct that governs your area of practice. Spend some time considering the standards discussed in the document and see if you can link them to the four ethical principles listed above. If you do not have a code of practice within your discipline, you can try the activity with either the UK or Irish Code of Practice at the links below.

The Code (Nursing and Midwifery Council, 2015)

Code of Professional Conduct and Ethics (Nursing and Midwifery Board of Ireland, 2014)

To help assist, standardize and improve the quality of ethical decision making many ethical decision frameworks have been introduced (Park, 2012). According to Tschudin (2003) ethical decision making frameworks/models assist decision makers to examine:

  • Values & interests at stake and contexts in which decisions are made,
  • Strategies to achieve a resolution of identified, problems
  • Nature of health professionals’ responsibilities in a situation.

Ethical decision-making processes assist in moving a situation forward by considering how a dilemma can be turned into a problem Tschudin (2003).

While models are helpful they do not provide a fool proof formula.

Parks (2012) describes an ethical decision making model which he designed based on a systematic review of 20 currently available structured ethichal decision making models. The steps in Parks Integrated Model are contained int the table below.

Step Actions
Step 1: State an ethical problem (in terms of ethical values). Is this an ethical issue? Or a communication, clinician patient relationship or legal problem? Characteristics – temporal urgency? Magnitude of consequences? Does the ethical problem already exist? More information?
Step 2: Additional information collection and analysis of the problem Who are the actors? Do they need information? Biological, psychological, social-historical or goals, preferences and values information? Decision maker? Is the stated ethical problem correct, if not correct and restate.
Step 3: Develop alternatives and analyze and compare them Which one has priority following above? Think about another option and challenge it. Assuming previous implementation, consider – legal test, front page test, gut feeling test, role model test and professional standard test.
Step 5: Develop strategies to successfully implement the chosen alternative and take action All of the health care team need to participate in developing the best way to implement the ethical decision.
Step 6:Evaluate outcomes and prevent a similar occurrence Evaluate outcomes and decision-making process. Future preventative strategies (individual, institutional and community/societal level)

Use Parks (2012) Integrated Ethical Decision Making Model to work through the following ethical issues which are related to working with the family.

Scenario 1
Julie is a 15 year old who you have been visiting in the community for 18 months. She has a history of self harm, low mood and weight loss. You ask her to keep a diary of her thoughts and feelings as a way of managing her self harm and other problems. Julie only agrees to keep the diary on the condition that you are the only one with access to it. Recently, her mother has inquired about the diary and wants to read it. She states that as Julie's mother she has every right to read the diary. In the diary, Julie has made a lot of disparaging remarks about her mother which you know might harm the integrity of their relationship.
Scenario 2
John is a 72 year old man with Alzheimer's Disease who is being cared for in a residential unit. His wife visits every day and helps John with his evening meal. When she is ready to leave she asks one of the nurses to take John to the bathroom to use the toilet. While he is in the bathroom, his wife slips out of the building. When John emerges from the bathroom, he is anxious and distressed but unable to articulate why. This happens every day and you feel there is a direct link between Johns agitation and his wifes departure.
Scenario 3
Justin is a 20 year old who lives at home with his parents. He has a medical diagnosis of schizophrenia and has been prescribed atypical anti-psyhotics by his consultant psychiatrist. While you are visiting him at home Justin confides that his mother will not let him take the medication even though he feels that they makes him feel better. His mother feels that if Justin attended church more often his would have less problems.When you mention this to Justin's mother she becomes angry and asks you to leave the house and not return.

The study of ethics is essential for mental health professionals who are working closely with families. Professionals need to be aware of the ethical principles that guide their everyday practice and be able to utilise ethical decision making frameworks when dilemmas emerge. Furthermore, professionals need to be able to recognise when and how to access support and guidance to assist them in ethical decision making when necessary.

Gallagher A. (2013) The ethics of mental health nursing. The Art and Science of Mental Health Nursing: Principles and Practice 3rd Edition. (Normal I. & Ryrie I., eds), Open University Press, London, pp. 155 - 167.

Park E.U. (2012) An integrated ethical decision making model for nurses. Nursing Ethics 19(1), 139 - 159.

Robertson M. & Walter G. (2014) Ethics and Mental Health: The Patient, Profession and Community. CRC Press, London.

Tschudin V. (2003) Ethics in Nursing. The Caring Relationship. Butterworth, Heinemann, Edinburgh.

Wheeler H. (2012) Law, Ethics and Professional Issues for Nursing: A Reflective and Portfolio Building Approach. Routledge, New York.

As the laws and regulations regarding mental health differ in and between countries, comprehensive presentation on these issues is difficult. However these issues are extremely important, therefore we advise you to familiarize yourself with the national laws and regulations that exist in your country.

When working with families there might be some issues that are especially important in mental health settings.

Below are a list of of reflective questions to guide you:

  • If an adult service user denies family's participation in care, are you allowed to contact them? If you think you are, elaborate on which cases its possible to do so? Are there some limitations?
  • What if you are working with children, adolescents or older people? Is the situation different then, and if so, how?
  • If you are working in the hospital setting and the service user does not want you to contact his or her family, what should you do? Are you allowed to ask again?
  • What if you are working in a community mental health setting? Is there some specific issues you should know about in relation to the family?
  • In what cases should you not contact the family?
  • Are there some specific issues with documentation? For example, how do you document permission to contact the family?
  • Are you allowed to document family member's details or just make a note that some family members were met?

If you are doing research there are several guidelines to be found and to follow if vulnerable groups like children or mental health service users are participating. This research viewpoint is excluded from this material.

The Universal Declaration of Human Rights

Convention on the Rights of the Child

UN Convention Rights of the Child on the In Child Friendly Language

WHO Mental health, human rights & legislation

European Federation of Associations of Families of People with Mental Illness (Eufami) Declarations and Position * papers

Mental Health Europe (MHE) Position papers

Code of Ethics for Nurses

European Psychiatric Nurses (Horatio) Position papers

World Medical Association (WMA) International Code of Medical Ethics

The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein.