Autonomy Vs. Paternalism In Mental Health Treatment

Essay, Research Paper

Autonomy Vs. Paternalism In Mental Health Treatment

The assignment for this Ethics class was to review Mr. Jacob’s treatment,

as described by the New York State Commission on Quality of Care for the

Mentally disabled (1994). The class was further asked to comment on the major

issues for each of the three perspectives. The agencies, family and review

board were to be included. This student will begin with a fourth perspective;

that of Mr. Gordon.

In the Matter of Jacob Gordon (1994), is the story of the last eight years

of a psychiatrically disabled man’s life. Mr. Gordon appeared to vacillate

between striving for autonomy and accepting the support of his family.

Unfortunately, it appeared by this account that the families support was not

synonymous with autonomy. It did not appear that Mr. Gordon had ever desired or

sought agency intervention for himself. Mr. Gordon’s association with the

mental health system appeared to be marked by power and control issues.

“Consumers/ex-patients often report a feeling of “invisibility”; they sense that

their views and desires do not matter (Carling, 1995, p.79 ).”

The commission’s report (1995) spoke of several incidences where Mr. Gordon

eluded to his desire for autonomy. Mr. Gordon did not wish to live in a

supervised setting. Mr. Gordon did not wish to attend group day treatment

settings. Mr. Gordon did not wish to use medication in the treatment of his

mental health disorder. Without medication his behavior was deemed unacceptable

and did not permit him the opportunity to have any of these choices. “Choice is

a right-not a privilege to be afforded by good behavior (Penny, 1994, p. 29).”

Mr. Gordon’s right of choice was limited even though he lived in his apartment

independently. The condition of his apartment was scrutinized. His medication

was closely monitored; sometimes to the degree that he was directed to leave his

home to receive medication that was given to him crushed, in an attempt to

insure it’s ingestion. “Even peoples liberties in a highly controlled board and

care home may be scarcely greater than in a hospital ward (Rubenstien, 1994,

p.54).” In Mr. Gordon’s case even within the sanctity of his own home, his

liberties were scarcely greater than in a hospital ward.

Other than his autonomy the second issue for Mr. Gordon appears to be the

need for safety and support. For this, Mr. Gordon turned to his family. The

report (1994) points out that Mr. Gordon requested his mother be limited in her

ability to access personal information. He continued to need her support and

assistance although this met she continued to be overly involved in his life.

It was his mother he turned to when he had problems with a roommate. It was his

mother who was utilized when Mr. Gordon was less compliant. It was Mr. Gordon’s

family who assured that he had continued mental health counseling and services.

It was also Mr. Gordon’s family who appeared to be the focal point of any plans

for Mr. Gordon. “……expectations, soon to be dashed by programs more devoted

to servicing neurotic families than people with schizophrenia” (Rubenstien, 1994,

p.55). Mr. Gordon remained safe and close to his family by relinquishing his

autonomy.

Mr. Gordon’s safety was the most important issue for the family.

Secondarily to his safety, Mr. Gordon’s family wished him to have the

opportunity to participate in programming that would assist in his wellness.

For Mr. Gordon’s family, wellness seemed to equate to a standard of behavior

that his mother personally viewed as normal.

The family were not bound to any code of ethics or compelled to understand

their biases or prejudices in their son’s case. Certainly, to say that the

family operated on the premise of paternalism is an understatement. Ethically,

the Gordon’s believed that they were the most justified to speak in the best

interests of their son. The energy that the Gordon’s put into advocating for

what they believed, was in their son’s best interest, is a testimony to the

depth of the feelings they had for their son.

The agencies primary issues appeared to be their liability and

responsibility. Looking at the commission’s report and attached responses from

agencies (1995), it appears as though all of the agencies and practitioners

involved were overly respectful of the involvement of Mr. Gordon’s family. This

over-involvement with Mr. Gordon’s mother was understandable when it was

disclosed that she had complained to state officials, whenever agencies did not

respond in a way that she believed to be acceptable. It appears as though Mrs.

Gordon understood very well, who to speak with and what to include as pertinent

information, when she desired action. As the case proceeded, it became evident

that Mrs. Gordon was the most active planner of her son’s services.

“Exaggerated fears and misconceptions associated with a lawsuit in high-risk

clinical situations rarely bring out the best quality in practitioners.(Corey,

Corey, & Callanan, 1993, p. 117). In actuality, the agencies involved were

far more open to a lawsuit in terms of the lack of information that they choose

to divulge to their client, Mr. Gordon. “A precaution of malpractice suit, is

personal and professional honesty and openness with clients (Corey, et al., 1993,

p.131).”

Mr. Gordon never had the right to choose any of his treatment. He was

never given all of the information concerning the selection of choices of

services, or the possible consequences of his choices. Rooney (1992) points out

the need for close scrutiny of ethics whenever agencies interfere with a

client’s autonomy. In an attempt to plan in Mr. Gordon’s best interest, appease

Mrs. Gordon and become less liable for any poor outcomes to the treatment plan,

the agencies acted paternalisticly. Agencies imposed paternalism in each of the

ways cited by Rooney (1992), by opposing Mr. Gordon’s wishes of no medication.

The agencies withheld information about the possible side effects of the

medication he took, and the consequences of not taking medication. The agencies

provided deliberate misinformation by allowing Mr. Gordon to believe that they

were excluding his mother from the planning process.

Agencies were also concerned with their own perceived responsibilities for

Mr. Gordon’s plan. Unfortunately, each agency choose to give as much

responsibility as possible to Mr. Gordon’s family. As the history of Mr.

Gordon’s treatment unfolded, it appeared evident that Mrs. Gordon was

responsible for the development and supervision of Mr. Gordon’s care. She

coordinated all of the service providers, and was the main contact from one

provider to the next. She became the “enforcer” for the plan, and who was

ultimately consulted if Mr. Gordon refused to cooperate. As agencies became more

controlling of Mr. Gordon’s life (in response to Mrs. Gordon’s concerns), Mr.

Gordon became more non-compliant. “Ethical dilemmas arise when there are

conflicts of responsibilities. For instance, when the agency’s expectations

conflict with the concerns or wishes of the clients (Corey et al., p.135).” It

appears that toward the end of Mr. Gordon’s life, none of the agencies were

involved in a team approach in the delivery of services to this man. Each

agency was involved in doing what they believed they were mandated to do for Mr.

Gordon, and relied on Mrs. Gordon to coordinate and collaborate when necessary.

The review board appeared to be most vested in singling out an agency to

pronounce as responsible for the problems in the care of Mr. Gordon. Sundram

(1994) writes of the changing paradigm from medical models of care to a client-

centered approach to delivering services. Ironically, speaking on behalf of the

same commission who wrote the review of Mr. Gordon, Mr. Sundram focuses on the

need for changes within the rank and file of service providers to empower

consumers. “We need to focus on ways to promote informed, voluntary choices of

people with disabilities, to provide options that allow them to meet self-

identified needs” (Sundram, 1994, p.8). Yet in its’ report about Mr. Gordon

(1995), the commission pointed out the agencies deficits in attempting to assure

Mr. Gordon’s medication compliance, and his compliance with exams necessary to

remain safely on medication. Mr. Gordon was reported by the commission to have

voiced his desire to discontinue any medication for his psychiatric disorder.

The commission recommended that if family involvement becomes an issue that

agencies deal with the families with the same diligence as other consumer issues.

Yet, it appears that Mrs. Gordon had much more power than the consumer. Mrs.

Gordon called the state office of mental health when she was dissatisfied.

Agencies seem to have paid much diligent attention to this family. Yet, the

commission and the Office of Mental Health believed that the family needed even

a greater amount of attention within Mr. Gordon’s care plan.

Ironically, it seems that one of the families issues in the care of Mr.

Gordon was his compliance with medication. The family advocated for agency

involvement and paid for private psychiatric intervention. Dr. Surles (1994)

the Commissioner of the Office of Mental Health writes a year prior to this

report (1995), a compelling piece on the balance and contradictions of choice

and safety. He clearly defines himself as a proponent for choice. Dr. Surles

(1994) writes “We cannot demand that the public mental health system insure

recipients choice and still guarantee recipients safety (p. 21).” “I simply

want to note that, in the area of treatment, recipient choice means not just the

right to refuse treatment, but the right to have access to treatment from which

to choose (p. 22)”. In responding to the concerns of Mrs. Gordon regarding her

son’s access to services, I am surprised that there is no mention by the

commission to the message that agencies serving Mr. Gordon received from the

Office of Mental Health’s intervention. I further question the level of the

Office of Mental Health’s investigation into the choices of Mr. Gordon in

relationship to his families wish for his safety.

The commission appears to be desirous to place responsibility on agencies,

for Mr. Gordon’s choices. The flavor of this feels as unjust as the

responsibility his family feels, and as unjust as the lack of choice Mr. Gordon

felt. “Both professionals and recipients are trapped in a system that gives

professionals too much responsibility and requires them to be accountable for

too much (Penny, 1994, p.31).”

The major conflict between the issues of choice, safety, liability, and

responsibility is a philosophical conflict between autonomy and paternalism. Is

freedom of choice a right that is truly inalienable and if so then should this

right ever be abridged for paternalism? If choice is the right of every citizen

than all parties involved in the case of Jacob Gordon acted in an unethical

and/or immoral way. The family looked upon thier child as less than a human ”

To deny an individual’s autonomy is to treat that person as less than human.

(Atkinson, 1991, p.106)”. The family was abusive to this person that they

claimed was the object of their concern. Jacob was disrespectful and abusive to

himself, in that he traded his autonomy for safety and belonging. “it is more

important for humankind to exert free will, than it is to be contented (Atkinson,

1991, p.105).” In this regard, Mr. Gordon could be considered incompetent,

since he was not interested in providing for himself the basic rights of his

culture. The agencies involved with Mr. Gordon were unethical as: counselors

“must recognize the need for client freedom of choice (Corey et al., p. 400)”,

psychologists “respect the rights of individuals to privacy, confidentiality,

self-determination, and autonomy (Corey et al., p. 415)”, and social workers ”

make every effort to foster maximum self-determination on the part of clients

(Corey et al., p. 430)”. The Commission on Quality of care was the most

unethical, as it is the mission of this agency to “require providers and

appropriate State agency officials to respond to the Commission findings, and to

provide periodic reports on the implementation of Commission findings, and to

provide periodic reports on the implementation of Commission recommendations (

Pamphlet, New York State Commission). The recommendations that suggested more

supervision not only spoke to the issues of autonomy for Mr. Gordon, but for

many other consumers served by the providers involved in this study and trained

with this information.

If paternalism is a societal obligation then Mr. Gordon was miserably

under-served, and all parties involved in his care were irresponsible, unethical

and liable for not keeping Mr. Gordon safe. The true measure of safety for Mr.

Gordon would have been long term hospitalization where all of his needs could

have been met.

It is sad to read case studies of people struggling with normalizing life

within a society that is uncertain of the issues involved in living with a

psychiatric disability. My sympathy lies with Mr. Gordon, his family, and the

providers involved with services for Mr. Gordon. I am sorry that the field of

psychology is so tentative about the types of treatment that assist people in

recovering from mental illness. Mr. Gordon certainly never appeared to be

relieved from his symptoms to a degree that was comfortable during the years

reported. His goals were aimed at normalizing his life, the same goals as every

other player in this tragedy. Mr. Gordon’s objectives in reaching that goal

were at odds with the other members of his treatment team.

The Gordon family certainly deserves recognition for the role they played

in being available and supportive of Mr. Gordon’s recovery. Mrs. Gordon seems

the type of person that would have done anything to assist her son in his

wellness, anything except risk harm to him. I empathize with her feeling of

fear that her son was not receiving what he needed.

The psychiatrist involved in Mr. Gordon’s care seems to be rather

mysterious, as we have little information about this provider. Frustration is

inevitable when dealing month on end with a patient that shows little progress

in diminishing the symptoms of his illness. Regardless of the amount of success

therapy yielded the doctor never abandoned his client. As Mrs. Gordon was

extremely pro-active in her son’s treatment, the doctor’s persistence was

undoubtedly great.

Lastly, the service providers worked reportedly countless hours to assist

Mr. Gordon in becoming independent. In spite of the labyrinth of rules and

regulations and concerns for conduct, these people gave Mr. Gordon unconditional

care. The report reflects the maneuvering agency staff attempted to assist Mr.

Gordon in accepting care that they believed would give him the lifestyle he

wanted. I suspect that each of those agencies, at one time, gave Mr. Gordon all

they could to assure his autonomy and his safety. Since these concepts do not

mix, they worked in futile effort and likely were aware of this.

Mr. Gordon’s case will become important in the way services are delivered,

when either the laws provide for consumers rights to choices and

responsibilities, or agencies obligations to make choices and become responsible

for the consumers safety.

“Can’ t you give me brains?” asked the scarecrow.

“You don’t need them. You are learning something everyday. A baby has brains,

but it doesn’t know much . Experience is the only thing that brings knowledge,

and the longer you are on earth the more you are sure to get”

The Wizard of Oz Frank L. Baum

REFERENCES

Atkinson, J. (1991). Autonomy and mental health. In P. Barker & S. Baldwin

(Eds.), Ethical issues in mental health (pp.103-125). New York: Chapman & Hall. Carling,

P.J. (1995).

Return to Community Building Support Systems for People with Psychiatric

Disabilities. New York: The Guilford Press. New York State Commission on

Quality of Care for the Mentally Disabled, (1995).

A Report. In The Matter of Jacob Gordon: Facing the Challenge of Supporting

Individuals With Serious Mental Illness in the Community. New York:

Commission on Quality of Care for the Mentally Disabled. New York State

Commission on Quality of Care for the Mentally Disabled.

A Pamphlet. What is The Commission? New York: Commission on Quality of

Care for the Mentally Disabled. Corey, G., Corey, M.S., Callanan, P. (1993).

Issues and Ethics in the Helping Professions. (4th ed.). California:

Brook/Cole Publishing Co. Penny, D.J. (1994).

Choice, common sense, and responsibility: the systems obligations to

recipients. In C. J Sundram (Ed.), Choice & Responsibility (pp. 29-32). New

York: NYS Commission on Quality of Care for the Mentally Disabled. Rooney,

R. (1992).

The ethical foundation for work with involuntary clients. Strategies for

Work with Involuntary Clients. (pp. 53-74). New York: Columbia University

Press. Sundram, C.J. (1994).

A framework of thinking about choice and responsibility. In C. J.

Sundram (Ed.), Choice & Responsibility (pp. 3-16). New York: NYS Commission

on Quality of Care for the Mentally Disabled. Surles, R.C. (1994).

Free choice, informed choice, and dangerous choices. In C.J. Sundram

(Ed.), Choice & Responsibility (pp. 17-24). New York: NYS Commission on

Quality of Care for the Mentally Disabled.