Mental health has become a massive part of medicine in the UK with almost 300 in every thousand being known to have a form of a mental health condition. Over the years debates have been ongoing in regards to the situation of physical restraint on mentally ill patients. Organisations such as Mind UK have proposed new laws be enforced after such incidents. Between 2011 and 2012 in England alone there were 3,479 incidents of face down physical restraint with nearly 1,000 of these patients suffering significant injuries. In this essay I will attempt to answer the question of ‘is it ethical to use restraint when treating patients with a mental illness’. I will look at the general background and then also compare a case study to two ethical theories.
Ethics are a simple system of moral principles that affect how people lead their lives and make decisions (BBC.co.uk). Ethics are a study of good and bad, moral duty and moral obligations and concerned with doing well and avoiding harm (Pojman2009). Healthcare professionals encounter ethical decisions and issue and it is important to understand ethics and their values to deliver quality healthcare.
Mental health worldwide is one of the primary disabilities reported and mental health behavioral problems such as anxiety and depression are reported to be the main types of mental health. Major depression is one that is commonly diagnosed and thought to be the major contributor to suicide and cardiovascular problems (Mental Health Foundation). NHS England states that one in four adults and one in ten children experience mental illness during their lifetime, and many of us know or care for people who do. Although mental health is such a worldwide problem evidence suggests that one in four have not contacted a medical professional about their illness. Around 300 people in 1,000 will experience mental health problems every year in Britain with 24 being referred to specialist psychiatric services and 6 becoming inpatients in psychiatric hospitals (mind.org.uk, July 2007). People being held in psychiatric hospitals are held under the mental health act and are said to have been sectioned. In 2001 approximately 98& of people detained for treatment under the mental health act were categorized as ‘mentally ill’ (mental health alliance.org.uk). In 2007 the mental health act was amended to make it explicit that people with dementia, personality disorder, autism spectrum disorder (ASD), and those with mental or behavioral disorders are included in the act where they were not in the 1983 act (Mental Health Act 2007, p.1,c.1 (1)).
The mental health charity Mind launched an independent enquiry into acute and mental health crisis healthcare in 2010 asking individuals about the realities of acute and crisis care in the UK and Wales. A discrepancy of care between different NHS trusts also manifests itself in the use of restraint in acute wards. The most ethically contentious form of restraint for people with mental illness is physical restraint, although the other forms of restraint carry their own ethical considerations. Physical restraint is an extreme response to managing someone’s behavior when they are in a mental health crisis. It can be humiliating, cause severe distress and at worse can lead to injury or death (Mind June 2013). This is one persons account of physical restraint on an acute unit: “It was horrific…. I had some bad experiences of being restrained face down with my face pushed into a pillow. I can’t begin to describe how scary it was, not being able to signal, communicate, breathe or speak (Mind 2013 p.2). Physical restraint should always be used as a last resort, but the practice is open to abuse and this is not always what happens. However the ethics behind physical restraint of someone who is mentally ill has always been a controversial subject and this is something I will look at in the next sections.
Restraint is one of the most talked about practices in mental health care and the use of physical restraint in acute settings is a widespread issue and often discussed as over used (Happell and Gaskin. 2011). The term restraint includes either physical or chemical; physical restraint is any manual method or physical or mechanical device, material or equipment attached that restricts freedom of movement (Regan, et al .,2006). Chemical restraint is a medication used to control behavior or to restrict freedom of movement and is not a standard treatment for the patients medical or psychiatric condition (Regan, et al,. 2006).
Two ethical theories I will use to compare and contrast restraint on mentally ill patients are Utilitarianism and Kantian Ethics. These theories are completely different as Utilitarianism looks at the theory that you should do the ‘greatest good for the greatest number’ and attempts to promote the greatest happiness for all concerned. This theory looks at the consequences of actions. So if an act has the best outcome for the greatest number then the act would be ethical regardless of consequences. Whereas, Kantian ethics look at the theory that ‘everyone should have their freedom so long as you don’t impose on the freedom of others’. He also stated that duty means emotions shouldn’t rule your head. Kantian looks primarily at behaving morally is a matter of obligation for which there would be no exception – hence emphasis on rules rather than the consequences. Kantian uses Beauchamp and Childress to uphold his theory. These principles are one used in biomedical ethics and the clinical setting.
On February 6th 2004 The Guardian released a report on How the death of one black patient treated as a ‘lesser being’ showed up race bias. This report basically looks an inpatient in medium secure clinic died after physical restraint was used to subdue him during an altercation. David Bennett was a 38 year old African Caribbean suffering from schizophrenia. This report looks at two questions. First, was the decision to restrain Mr. Bennett based on culture and Secondly why was Mr. Bennett being restrained for an unsuitable period of time by untrained staff and no suitable medical professionals within 20 minutes distance. Mr. Bennett sustained injuries consistent with excess pressure being used. His capacity to breathe was restricted. By the time they had realised Mr. Bennett had stopped breathing it was too late. Staff attempted resuscitation via oxygen therapy but by the time an ambulance arrived Mr. Bennett had been without adequate resuscitation for over 10 minutes.
The two ethical theories I have chosen to link to this case study are of complete differences. Utilitarianism looks at the theory of no moral act being right or wrong but the consequences decide if a moral act would be right or wrong dependent on the happiness of the of the greatest number. In Mr. Bennett’s case was the act moral or immoral? The act could be justifiable if they are looking at the rest of the inpatients as the greatest number but on the other hand it would mean that Mr. Bennett would be a minority, which would initiate the obvious racism claims shown in the case study. In the case study Mr. Bennett believed that he was a victim of racism and was being shifted because he was black, again looking at theory of a minority. With this theory staff were unable to predict the consequences and just decided to restrain Mr. Bennett after he hit the nurse and this is one of the big dis-advantages with this theory. With the theory saying that circumstances would change the morality of an action, with no absolute right and wrong, wouldn’t it just become possible to justify any action as ethical because in one situation the consequences would be for the best where as in another the consequences would be bad but be better for the greatest number. The theory looks at the fact that the human life has no value and the theory should be upheld no matter what. Was there a different way to deal with this patient? A more humane way perhaps? Finally, how do you define pleasure? Pleasure means different things to different people and to different situations/religions.
In Kantian Ethics it looks at the theory of ‘everyone should have freedom so long as you don’t impose on the freedom of others’. It also looks at the idea that ‘no action is good without the intention of goodness being there’. When staff restrained Bennett was there goodness in the action? I would argue that yes there was. Bennett assaulted a member of staff and regardless of the reasons for this, he was restrained to protect the member of staff from further harm. In the first instance you could argue that this is a good enough example of ‘goodness’ being the end goal. Looking back to the first statement in which Kant describes this theory as ‘everyone having freedom so long as the freedom of others is not imposed’, did Bennett impose on the freedom of other patients and also the staff member? Was restraint conducted in a way that was to protect someone? I would argue that yes it was and in which case the consequences are irrelevant.
Mental health plays a massive part of medicine and contributes to a large amount of people and resources. 6 in 1000 become psychiatric inpatients and if restraint is used with every patient this becomes a significant problem that needs addressing. To conclude we looked at the case study of David Bennett and linked this to two ethical theories contrasting and comparing these to the case. Looking at all of the information it is almost impossible to answer the question of “is it ethical to use restraint when treating patients with a mental illness?”. This is because the two ethical theories used have different values and contradict each other. Utilitarianism looks at the idea of no moral act being right or wrong but the consequences decide on the morality of the act, whereas, in Kantian ethics it looks at the idea of goodness being the end goal and if the initial act is to provide goodness then the consequences are irrelevant. It all comes down to how the act is initially portrayed. Is it for the happiness of the greatest number or to protect somebody? Are there other treatments available? Should untrained staff members undertake restraint?