Moral and Ethical Issues Encountered by PMHNPs

Moral and Ethical Issues Encountered by PMHNPs



Moral and Ethical Issues Encountered by PMHNPs

Although psychiatric mental healthcare nurse practitioners are legally required to protect the confidentiality of mental health information disclosed by their patients, most states have laws either mandating or permitting practitioners to reveal confidential information when patients pose harm to a third party.

Most of these laws, commonly referred to as “duty to warn” laws, were passed following the seminal court case of Tarasoff v. The Regents of the University of California (Rothstein, 2014). This case established a duty among mental health professionals to warn potential victims of a risk of violence. The laws afford mental health professionals’ immunity from civil and criminal liability for the disclosure of confidential mental health information under certain conditions (Rothstein, 2014). It is important for healthcare providers to familiarize themselves with the privacy provisions for Duty to protect and laws within the state they are practicing.

Moral and Ethical Dilemmas in Adults

According to HIPAA guidelines, mental health providers, like other health care professionals, are subject to liability for breaching provider-patient confidentiality. However, although the duty to protect, as delineated in the Tarasoff decision, is intended to relieve providers of such liability by mandating that they alert others of a possible threat from a patient, an incorrect reading of a situation could have the opposite effect (Rothstein, 2014). Precisely, in a situation in which a provider strongly feels that a particular circumstance justifies a breach of provider-patient confidentiality but is ultimately mistaken, the provider could then be held liable to the patient for the breach, irrespective of any good intention on the part of the provider (Rothstein, 2014).  In Opposition, a provider who favors confidentiality over the issuance of a warning could be subject to civil liability for negligence to any threatened third party (Rothstein, 2014).

Often over the course of treating a client with HIV disease, the psychiatrist may encounter situations that generate safety concerns. Clients who are in advanced stages of HIV may suddenly become weak and unable to perform normal activities (Barret et al., 2001). Sometimes dementia may be observed first by the mental health practitioner (Barret et al., 2001).  The ethical principle requiring respect for the client’s autonomy may clash with the duty to protect both the client and the public. Consultation with medical personnel may help relieve these situations, but often more direct action may be necessary. The American Nurses Association requires that APRNs deliver care in a manner that preserves and protects healthcare consumer autonomy, dignity, and rights, while demonstrating a commitment to practicing self-care, managing stress, and connecting with self and others (ANA, 2014).

Moral and Ethical Dilemmas in Children / Adolescents

Problems of professional liability in the treatment of adolescents are complex and multifaceted. Adolescence exists in a murky area between childhood and adulthood socially, psychologically, and legally. Although adolescents must engage in their own treatment, their parents or guardians retain legal decision-making capacity (Tuckman & Ferro, 2004). Treating adolescents almost always entails engaging family members, which also creates a complex web of relationships and obligations (Tuckman & Ferro, 2004). Attorneys have crafted causes of action that have created new classes of liability for psychiatrists. Such actions have suggested new duties for psychiatrists such as providing informed consent for psychotherapy, handling repressed memories, and assuming responsibility for harm that psychiatric patients inflict on their relatives or even the public (Tuckman & Ferro, 2004).

Mississippi State Law

In Mississippi, the duty to warn is permissive. Mississippi Miss. Code Ann. §41-21-97 Physicians, Psychologists, Licensed Master Social Workers or Licensed Professional Counselors (Soulier et al., 2010). When the patient has communicated to the treating physician… an actual threat of physical violence against a clearly identified or reasonably identifiable potential victim or victims, and then the treating physician… may communicate the threat only to the potential victim or victims, a law enforcement agency, or the parent or guardian of a minor who is identified as a potential victim (Soulier et al., 2010). There also should be a termination note that will likely reduce exposure to arguments about continued duty of care and reduce the risk of responsibility if a duty to protect/warn context should emerge (Soulier et al., 2010).


Barret, B., Kitchener, K. S., & Burris, S. (2001). The HIV-positive disabled client: The case of

Mike. In J. R. Anderson & R. L. Barret (Eds.), Ethics in HIV-related psychotherapy:

Clinical decision making in complex cases. (pp. 249–260). American Psychological

Association. Retrieved from

International Society of Psychiatric-Mental Health Nurses, R2 Library (Online service),

American Nurses Association, & American Psychiatric Nurses Association.

(2014). Psychiatric-mental Health Nursing : Scope and Standards of Practice: Vol. 2nd

edition. American Nurses Association. Retrieved from nlebk&AN =1021972&site=eds-live&scope=site.

Rothstein, M. A. (2014). Tarasoff Duties after Newtown. Journal of Law, Medicine &

 Ethics42(1), 104–109. Retrieved from

Soulier, M. F., Maislen, A., & Beck, J. C. (2010). Status of the Psychiatric Duty to


AND THE LAW38(4), 457–473. Retrieved from


Tuckman, A. J., & Ferro, D. (2004). Professional Liability and Malpractice in Adolescent

Psychiatry. Adolescent Psychiatry28, 59–75. Retrieved from edb&AN=184139