Although they could provide the care, what were the ethical principles inferred by some of the medical staff objections to Bentley's admission to Mountain State Hospital?

Over the past five years, Bob Allred, Administrator at Mountain State Hospital, recognized that magistrate and district judges across his rural state had been increasingly directing that dangerous and severely mentally ill patients be placed under the charge of the state's Department of Health and Human Services (DHHS). Although he was deeply conflicted and troubled, All red as the administrator of the hospital that was under the auspices of DHHS, was not entirely surprised then when he was directed to accept and admit a mentally ill patient who had a history of violent crime, including aggravated assault and murder. Allred's rural state was one of just a few states in the U.S. that did not own, operate, or contract with a secure forensic mental hospital—mainly because of poor funding and/or unwillingness to receive transferred patients because of limited capacity or overcrowded conditions of their own. As a result, severely mentally ill criminals who required significant mental healthcare either languished without needed psychiatric care and medications in secure, lock-down units in county jails or the state penitentiary, or they were admitted to minimally-secure civil units at state-owned/operated or contracted hospitals where they received much needed care, notwithstanding the risk they posed to others.

The Hippocratic imperative to physicians: "Bring benefit and do no harm," expresses the principles of nonmaleficence: "do no harm" and beneficence: "bring benefit." By its very declaration, the Hippocratic Oath invites trust. The doctor, and those who work with and for him, voluntarily promise that they can be trusted to "bring benefit" while, above all, pledging to "do no harm," (Paola, Walker, and Nixon, 2010). As Allred and his colleagues would learn, balancing these imperatives is, at times, extraordinarily difficult.

State Law, Social/Political Realities, and Incompatibility

Consistent with other states, Allred's local state legislature had enacted statutes which required the DHHS (notably the state's network of clinics and state hospitals) to evaluate and treat all severe and persistent mentally ill citizens who were not otherwise treated by private mental hospitals and clinics. Allred's state statutes also required that dangerously mentally ill patients and/or criminals be treated in properly designated forensic (lock-down/secure) hospitals and/or facilities. In 2005 Allred's state did not have separate and distinct facilities for: (a) civil and non-dangerous mentally ill citizens, and (b) dangerous/criminal/forensic patients. Thus, two great conflicts routinely (and increasingly) came into play: (a) dangerous patients were placed and cared for alongside vulnerable patients/staff in non-secure settings – thus violating state law; and/or (b) dangerous/forensic mentally ill patients who, for reasons beyond their control (mental illness), were denied access to desperately needed care and medication available in state hospitals—instead left to languish in county jails and state prisons for unreasonable lengths of time. While most states have long since resolved the difficult matter described above, Allred's state—with its limited funds and highly conservative views on welfare and state-provided mental healthcare—continued to operate without the needed facilities and ranked near the bottom nationally in mental healthcare spending per capita.

Allred's state law provided that severe and persistent mentally ill citizens were to be cared for in a safe, secure environment. But without a separate forensic health facility to serve violent patients, the non-violent mentally ill were not afforded a safe, secure environment. Notwithstanding this dilemma, the violent mentally ill needed healthcare, too.

The Risk

As at other state mental institutions, personnel at Mountain State Hospital were regularly trained and oriented in matters of personal safety as relates to the risks inherent in caring for mentally disturbed patients. Although these risks are commonly understood and protective measures are routinely employed, employees and vulnerable patients still, on occasion, get injured. These injured staff and patients have even been known to file battery charges against their psychotic aggressors.

Notwithstanding these risks, accepting and caring for extremely aggressive and/or dangerously violent mentally ill patients at Allred's State Hospital created heightened risk for several constituencies. First and foremost were the other patients in the state hospital. If a violent, mentally ill patient were admitted, how could the other patients be protected from potential harm? The second concerned the hospital staff members who provided healthcare. How could their safety be assured, given their work environment had not been set up to deal with violent patients? Also, how could they guarantee safe care for the nonviolent mentally ill when violent mentally ill were nearby? The third concerned the public. What role would public opinion hold regarding the violent, mentally ill criminal being placed with the nonviolent mentally ill in a state owned hospital?

The Tipping Point

Allred sighed as he opened his desk drawer and removed the documents that had been sent over from his supervisor at DHHS. A district judge had directed the DHHS to accept and admit Mr. Harold Bentley, a middle aged man who, several years earlier, had violently murdered his supervisor. In his delusional state, Bentley believed his boss was out to kill him, and reacted accordingly. After being tried and convicted of first degree murder, (Allred's state did not have a" guilty but mentally ill" law) Bentley was admitted to life in prison at the state penitentiary. For four years, Bentley sat in prison—in near isolation—locked down in a four by eight foot cell 23hours per day. He had been given limited psychotropic medications with little other mental health evaluation or treatment. Thus, while the public was safe from what most regarded as a ruly violent criminal, mental health advocates plead in his behalf that he was not receiving mental healthcare.

For over three years the media followed Bentley's case, resulting in various feature stories from television and newspaper outlets. During this time, repeated appeals on Bentley’s behalf were entered into court. Advocacy groups that proposed Bentley’s removal from prison and placement into an acute mental healthcare facility had gathered favorable mental health evaluations in his behalf. Coupled with Allred's state statute that required DHHS to arrange for or directly treat all severe and persistent mentally ill citizens, the media were able to keep the Bentley story alive. In the most recent appeal, the judge, citing the favorable mental health professions evaluations, directed that Bentley be released from prison and admitted to Mountain State Hospital.

Allred and the Decision

Upon learning of the Judge’s ruling, various members of the Mountain State Hospital medical staff responded quickly. They told Allred they viewed the Judge’s order negatively and demanded he ignore the Judge’s ruling and refuse admittance to Bentley. They argued that Mountain State Hospital did not have the ability to care for a violent, mentally ill patient and that the medical staff leaders were within their rights to argue this point. Moreover, state law provided that the state Hospital Administrator consult with the hospital's Medical Director on matters related to all hospital admissions, and as a result of their consultation, they had the legal right to accept or reject patients based on the hospital's ability to care for such patients in a safe and effective manner. To further demonstrate their negative view of Bentley’s admittance, two of the seven leaders threatened to resign if Bentley were to be admitted.

Other hospital caregivers (e.g., psychologists, nurses, social workers, etc.) were mixed on their opinions regarding Bentley’s admittance. Some expressed that Bentley needed the care and that“ we are or should be the obvious providers of that care." Others were more verbal supporters of the medical staff's view. One nurse commented, “We should care for our patients—the nonviolent mentally ill; the violent should not be allowed in the facility. I can’t keep my vulnerable patients safe with dangerous and violent patients around!”

Beyond the medical staff, Allred had another constituency with a markedly different demand. Because of its state hospital status, Mountain State Hospital operated under the direction of the Department of Health and Human Services (DHHS). Any decisions made by Allred and/or the Medical Director could be heavily influenced by DHHS officials. Thus, notwithstanding the medical staff leaders’ position, DHHS officials strongly encouraged Allred to admit Bentley. In fact, Allred’s supervisor at DHHS had all but demanded that Allred follow the Judge's directive and admit Bentley to Mountain State Hospital.

Allred reread the Judge’s order. What should he do? Should he follow the Judge’s order and DHHS’s directive to admit Bentley? Should he follow the demand by his medical staff leadership not to admit? To begin this decision making process, Allred took out a piece of paper and listed the key players and how he saw their positions regarding Bentley’s admittance. He also considered various decision making models he had been introduced to in college and in more recent management books he had read (Drucker, 1974, 2001). Questions such as: Have you defined the problem accurately? How did this situation occur in the first place? What is your intention in making this decision? What is the symbolic potential of your action if understood/misunderstood? And under what conditions would you allow exceptions to your positions? (Nash, 1989). Allred hoped that by clearly identifying the key players’ positions, and following a thoughtful, rational decision making model, he would make the best decision, notwithstanding the difficult circumstances.