Underpinning this caveat is the reality that in most jurisdictions around the world there are legislative provisions that enable people with severe mental health illness to be detained, restrained, coerced and / or treated without their consent . For mental health nurses having the power to control and being expected to control people diagnosed with a mental disorder can be morally distressing, especially where situations do not always have clear outcomes. ISBN: 9780730344612. The test of ability to understand , on the other hand, asks whether the patient is able to comprehend the risks, benefits and alternatives to a proposed medical procedure, as well as the implications of giving consent. This is so despite what Callaghan and Ryan (2016 : 601) describe as a ‘revolutionary paradigm shift’ that is occurring as a result of Article 12 of the UN Convention of the Rights of Persons with Disabilities (CRPD) 1 ‘objecting to the automatic use of substituted decision-making whenever a person fails to meet a functional test of decision-making capacity’. This test asks how well the patient has actually understood information which has been disclosed. Here very practical questions arise of what, if anything, can be done to strike a balance between respecting the patient’s autonomous wishes and constraining their freedom where its exercise could be harmful to themselves and / or to others? Also, although some studies have suggested that clinicians are broadly supportive of the ‘advance-consent’ function of PADs (termed ‘prescriptive function’), clinicians are more reticent about their ‘advance-refusal’ function (termed ‘proscriptive function’) – especially if used to refuse all future treatment ( Swartz et al 2006 ). The rights and responsibilities of people who seek assessment, support, care, treatment, rehabilitation and recovery – encompassing the right of people (including children) to ‘participate in all decisions that affect them, to receive high-quality services, to receive appropriate treatment, including appropriate treatment for physical or general health needs, and to benefit from special safeguards if involuntary assessment, treatment or rehabilitation is imposed’ (p 12). A short case-study highlights potential solutions to those challenges. The main purpose of providing this information and alerting service providers to their preferred options is to ensure the continuity of their care, although research demonstrating this purpose remains inconclusive. While drawing primarily on the Australian experience, this discussion nonetheless has relevance for nurses working in other countries. The lack of conceptual clarity in this instance risks ‘pushing ethics to their limits’ – especially in cases ‘where patients have not reached out for help’ yet treatments are imposed without their informed consent ( Gustafsson et al 2014 : 176). People with serious mental illnesses can often experience periods of profound distress during which their capacity to make prudent and self-interested decisions about their care and treatment options can be seriously compromised. They make the additional value judgment that it would be ‘better’ for the patient if his psychiatric condition were prevented from deteriorating, and that their decision to administer his prescribed medication forcibly against his will is justified on these grounds. The need to do this becomes even more acute when the problem of determining and weighing harms is considered in relation to the broader demand to achieve a balance between protecting and promoting the patient’s wellbeing, protecting and promoting the patient’s autonomy, and protecting others who could be harmed if a mentally ill person is left free to exercise harm-causing choices (as happened in the Tarasoff case, considered in Chapter 7 ). Because of unresolved uncertainties concerning how the concept of competency is to be interpreted and applied by clinicians, and the tendency to overlook what Banner describes as the ‘inherent normativity of judgments made about whether a person is using or weighing information in the decision-making process’, there remains the ever-present risk of patients failing on the criteria ‘to the extent that they do not appear to be handling the information given in an appropriate way, on account of a mental impairment disrupting the way the decision process ought to proceed’ ( Banner 2012 : 3078; see also Stier 2013 and Light et al 2016 – both referred to earlier). Early proponents of PADs in the US expected that their use would spread ( Appelbaum 1991 ). On this point, with reference to the provisions contained on the CRPD, Callaghan and Ryan (2016 : 610) explain: Several years ago, a consumer advocate pleaded: It has taken a very long time but, it would seem, this advocate’s plea is at last being heard. For example, if a patient with severe mental illness decides to refuse hospitalisation, the extent to which an attending health professional is obliged morally to respect this decision will depend on how severe the risks to the patient are of not being hospitalised – for instance, whether a failure to hospitalise the patient will result in her or him suiciding, or will result only in her or him being left in a state of moderate, although not life-threatening, depression. This story is used controversially in philosophy to demonstrate the difference between freedom and autonomy: in this case, although Ulysses had his freedom constrained (i.e. Since then a substantive paradigm shift has occurred, which has seen PADs incorporated into mental health legislation in the Australian Capital Territory (2015), Queensland (2016), Victoria (2014) and Western Australia (2014), with the Australian Capital Territory legislation regarded by commentators as the most progressive (see comparative table in Ouliaris & Kealy-Bateman 2017 : 576). Only a few countries (e.g. The dilemmas are derived from a discussion of the results of a qualitative research project that took place in five countries of the European Union. Background: Ethical challenges are common in clinical nursing practice, and an infectious environment could put nurses under ethical challenges more easily, which may cause nurses to submit to negative emotions and psychological pressure, damaging their mental health. What else then should health care professionals do? A little over a decade later, in the cultural context of Australia, the need to assure the rights of people with mental illness and the ‘provision of recovery-orientated practice in mental health services’ was positioned as a core principle in the Australian Commonwealth Government’s National framework for recovery-oriented mental health services ( Australian Health Ministers Advisory Council (AHMAC) 2013 ) and the Council of Australian Governments’ (2012) Roadmap for national mental health reform 2012–2022 .

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