Please read the following and answer discussion question number 2:

the question is: In his effort to balance the competing interests of public safety with Bentley's rights as a citizen and potential patient, do you think the judge acted wisely in relocating Bentley from the state prison to the state hospital? Consider both the legal and ethical conflicts involved. explain!!!

INTRODUCTION

This book addresses many of the conceptual, interpersonal, and business skills associated with healthcare management. Among the material covered in part III are business skills related to healthcare law and ethics; strategic planning; healthcare operations and quality; financial management; human resources management; and healthcare information technology. Much of the knowledge and skill set needed to solve the complexities presented in this case require a practical application of the ideas presented in part Ill, as well as in parts I and II. Discussion questions at the end of the case will facilitate insight and learning.

BACKGROUND

Over the past five years, Bob Allred, administrator at Mountain State Hospital, had noticed that magistrate and district judges across his rural state were increasingly directing that dangerous and severely mentally ill patients be placed under the charge of the state's Department of Health & Human Services (DHHS). Although Allred was deeply conflicted and troubled abour this trend, as administrator of a hospital under the auspices of DHIHS, he was not entirely surprised when he was directed to admit a mentally ill patient who had a history of violent crime, including aggravated assault and murder.

Allred's rural state was one of only a few US states that did not own, operate, or contract wit a secure forensic mental hospital- mainly because of poor funding and other insinution. unwillingness to receive transferred patients because of limited capacity or overcrowds conditions of their own. As a result, severely mentally ill criminals who required significant mental health care often languished without needed psychiatric care and medications in secure, lockdown units in county jails or the state penitentiary. Alternatively, many were admitted to minimally secure civil units in hospitals contracted with, owned, or operated by the state, where they received much-needed care, despite the risk they posed to others.

The Hippocratic imperative to physicians "Bring benefit and do no harm

-expresses

both the principles of nonmaleficence ("do no harm") and beneficence ("bring benefit). By its very declaration, the Hippocratic Oath invites trust. Doctors, and those who work with and for them, voluntarily promise they can be trusted to "bring benefit' while, above all,

"(doing] no harm" (Paola, Walker, and Nixon 2010). However, as Allred and his colleagues would learn, balancing these imperatives is, at times, extraordinarily difficult.

STATE LAW, SOCIAL AND POLITICAL REALITIES, AND INCOMPATIBILITY

Consistent with other states, Allred's local state legislature had enacted statutes that required DHHS, notably the state's network of clinics and state hospitals, to evaluate and treat all citizens with severe and persistent mental illness who were not otherwise treated by private mental hospitals and clinics. Allred's state statutes also required that dangerously mentally ill patients or criminals be treated in properly designated forensic hospitals that is, secure hospitals able to keep patients on lockdown- or related facilities. In 2015, Allred's state did not have separate and distinct facilities for civil and nondangerous mentally ill citizens and patients deemed dangerous, criminal, or forensic. Thus, two great conflicts routinely, and increasingly, came into play:

Dangerous patients were frequently placed and cared for alongside vulnerable patients and staff in nonsecure settings, thus violating state law.

Dangerous or forensic patients who, for reasons beyond their control--often mental illness were denied access to the desperately needed care and medication available in state hospitals and instead left to languish in county jails and state prisons for unreasonable lengths of time.

While most states had long since resolved these difficulties, Allred's state- with is limited funds and highly conservative views on welfare and state-provided mental health care continued to operate without the needed facilities and ranked near the bottom nationally in mental health care 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 nonviolent 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 they relate 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.

Given these conditions, admitting and caring for extremely aggressive or dangerously violent mentally ill patients at Mountain State Hospital created a heightened risk for several constituencies. First and foremost were the other patients. If a violent, mentally ill patient were admitted, how could the other patients be protected from potential harm?

Second were the hospital staff members providing healthcare. How could their safety be ensured, given that their work environment had not been set up to deal with violent patients? And how could they guarantee safe care for the nonviolent mentally ill when violent mentally ill patients were nearby?

The third group at increased risk were members of the public. What dangers would they face when visiting the hospital? And, what if a violent patient escaped the building, into their community? Although potentially dangerous patients are guarded more carefully, the facility was not designed nor staffed to be a high-security hospital. If the public knew it was now accepting dangerous, mentally ill patients, they likely would object, making public opinion a concern.

THE TIPPING POINT

Allred sighed as he read the documents sent over from DHHS. A district judge had directed Mountain State Hospital to 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 he had determined to strike first. After being tried and onvicted of first-degree murder (Allred's state did not have a "guilty but mentally ill" law), Sentley was sentenced to life in prison at the state penitentiary. For four years, he had sat n near isolation, in a four-by-eight-foot cell, 23 hours per day. He had been given limited sychotropic medications and little other mental health evaluation or treatment. Thus, while the public was safely protected from this man whom most regarded as a truly violent criminal, mental health advocates pleaded Bentley's case, insisting he was not receiving needed mental health care services.

The media had followed Bentley's case for more than three years, 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 health care facility had garnered favorable mental health evaluations. Coupled with the 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 Allred's 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 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 hospital admissions, and because of this consultation, the medical staff 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 protest Bentley's admittance, two of the seven staff psychiatrists threatened to resign if Bentley were admitted.

Other hospital caregivers, including many psychologists, nurses, and social workers, had mixed opinions regarding Bentley's admittance. Some sympathized with Bentley and argued his need for care, even noting "we should be the obvious providers of that care." Others supported the medical staffs view. One nurse said, "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 DHHS. Any decisions made by Allred or the medical director were subject to influence by DHHS officials. Thus, despite the medical staff leaders position, DHHS officials strongly encouraged Allred to accept Bendley. In fact, Allred's supervisor at DHHS essentially demanded that Allied follow the judges directive and admit Bendey to Mounain State Hospital.

Allred reread the documents. What should he do? Should he follow the judges order and DHHS's directive to admit Bentley? Should he follow the demand by his medial staff leadership not to admit? To facilitate his decision- making process, Allred made a list of the hospital 's key stakeholders and their positions regarding Bentley's potential admission. He also considered various decision making models he had studied in college and read more recently in management books. A number of questions coursed through his mind (Nash 1989)

Have you defined the problem cortectly?

How did we get to this point in the first place?

What are the short- and long-term implications of your potential decision(s)?

What are the legal and ethical frameworks for your position?

What strategic, operational, human resources, or quality/safety considerations affect your potential decisions/positions?

Under what conditions would you allow exceptions to your positions?

Allred hoped that by clearly identifying key stakeholder positions, and by following a thoughtful, rational decision-making model, he would make a wise decision in the Bentley case.

DISCUSSION QUESTIONS

1. In his effort to balance the competing interests of public safety with Bentley's rights as a citizen and potential patient, do you think the judge acted wisely in relocating Bentley from the state prison to the state hospital? Consider both the legal and ethical conflicts involved. explain!!!