JUSTICE AND DIVERSITY

WORD COUNT 3846

Introduction
The aim of this assignment is to consider whether mental health patients have autonomy or do staff and the healthcare environment merely allow them a measurable quantity of autonomy based on legal, ethical and moral restrictions, if this is the case, is this autonomy at all? Placement experiences will be given in relation to patient autonomy and related ethical, legal and professional issues will be supported and/ or contrasted by relevant literature. Patient autonomy and capacity, consent, compliance, coercion and paternalism with be considered. In an attempt to show a deeper understanding and ability to apply theory to practice, the moral theories of liberal individualism, utilitarianism, Kantianism and communitarianism will be discussed in relation to patient autonomy. Attitudes, values, assumptions related to patient autonomy, implications for practice and care provision will also be reviewed. This topic has been chosen, due to personal interest following practice experiences on an adult acute mental health unit. All identifying factors relating to the patients have been changed to maintain client confidentiality (Nursing and Midwifery Council’s (NMC) Code of Professional Conduct 2002). A conclusion will be offered to evaluate findings, finalising with a reflective summary focusing on the process of enquiry.

Autonomy
Autonomy means self rule (Dworkin 1988). It as the ability to think, choose and act freely and independently (Gillon 1992). Each human being is part of a race of people, culture, sub culture or a community from birth. In any society we have rules, beliefs, attitudes and culturally defined norms. Each member in that given society cannot just act autonomously as they are expected to act within their societies moral and legal guidelines or risk prosecution, stigmatisation or isolation. It could therefore be asked whether one is ever completely autonomous or is autonomy merely measurable by the societies legal, ethical and moral restrictions and expectations of what is acceptable behaviour and what is not (Harris 1985). This principle can also apply to mental health patients’ in a healthcare setting where it can be asked to what degree, if any, does the patient have autonomy or do staff and the healthcare environment merely allow them a measurable quantity of autonomy based on legal, ethical and moral restrictions, if this is the case, is this autonomy at all?

Paley (1996) argues that the concept of autonomy is vague and needs clarity, as it is open to interpretation and ambiguity. Without a universal understanding of autonomy, this could have varying implications for patients’ and their care (Aveyard 2000). Kant (1964) argues that autonomy is a property of the will of rational beings. It could therefore be argued that to respect a patient's wishes and choices, staff must believe that the patient is acting with deliberation and rationality (Childress 1982). Autonomy may be restricted in healthcare settings because healthcare professionals may judge a patient’s ability to make rational decisions to be limited because of their psychotic illness (Svedberg 2001) Studies by (Jansson & Norberg 1989) and (Davidson 1990) would suggest that diagnosis does influence healthcare professionals attitude towards the validity of a patient’s ability to act autonomously and that some staff justified overriding patients’ autonomy by acting according to the principles of beneficence, whereas others respected the patients autonomous choices irrespective of their capacity to make autonomous decisions.

If respect for patient autonomy relies on staff judging them as either rational or irrational dependent upon their diagnosis, this will have implications for practice and will impact on patients’ experience of healthcare. Such judgements devalue and disempower patient autonomy, even if staff respect patients’ wishes, the fact remains that staff have the decision making control. Whilst on placement, two patients’, one under Section 3 of the Mental Health Act (1983) and the other informal, both refused their lunch and teatime meal, saying they felt unwell. Staff assumed the informal patient’s decision was rational, based on them felling unwell, but the sectioned patient was being irrational and merely seeking attention. Whilst staff accepted both patients’ decisions they judged both patients differently due to their interpretation of the meaning of autonomy and the patient’s diagnosis.

Autonomy and Capacity and Consent
Whilst the rights of each individual must not be abused or restricted by another (Article 17 & 18 of the Human Rights Act 1998) there are occasions when legally under the Mental Health Act (1983) healthcare professionals’ have the right to remove an individual’s right to liberty and as such the ability to act autonomously, as long as the individual is deemed at risk to themselves or others. According to Article 5 of the Human Rights Act (1998) everyone has the right to liberty unless they are lawfully detained under the justification of being of an “unsound mind”. Mental incapacity can be defined as the inability by reason of mental disability to make an autonomous decision or give informed consent on the matter in question (Treloar, Philpot, Beats 2001).

The principle of autonomous consent can only be applied to those patients’ who can comprehend and evaluate given information to arrive at a decision. In the cases of mental health patients’, Re C (1994) and Re F (1990) it was ruled that care or treatment, however paternalistic, beneficent or non-maleficence, could not be given without the autonomous action of informed consent from the patient. Healthcare professionals’ have a duty to respect the patients’ autonomy and their right to agree with or refuse care, even if it results in harm to the patient, unless a court of law orders to the contrary. It should not be assumed that a patient who is mentally ill is incapable of giving or refusing consent for treatment. You must give the legally competent patient, information about their condition and gain informed consent before giving treatment (NMC 2002). Faden & Beauchamp (1986) argue that agreeing to a procedure does not mean that a patient acted autonomously and gave consent, as they may not have been fully or adequately informed or mentally able to comprehend consent.

With the best intentions in the world how can healthcare professionals’ ever know as what is best, right or good for another human being? It is unlawful and unethical to neglect to treat a patient who cannot act autonomously due to incapacity and cannot give consent (Ayeyard 2000). On placement, a sectioned patient was given a depot injection without her consent. She suffered unpleasant side effects as a result of the injected medication. Had she been asked beforehand she had may have been able to explain that she didn’t want it because she had experienced problems with that medication in the past. Just because a patient is mentally ill does not mean to say they do not have the capacity to act autonomously as they may have. In this case, had she been able to make an autonomous choice regarding her care she may have been able to opt for a medication which she knew suited her and would not result in unpleasant side effects. This shows how patients know their illness and should be able make autonomous decisions relating to their care (Bunting 1993).

Autonomy and Compliance and Coercion
Patients’ who do not take their medication are seen as non-compliant and are labelled by staff as difficult and irrational. Compliance means “the extent to which the patients’ behaviour coincides with medical advice” (Haynes 1979 page 2). However, Fletcher (1989 page 453) defines it, as “patients’ doing what the health professionals want them to do.” Labelling a patient as irrational is justified by staff because the patient is mentally ill and as such their non-compliance is a symptom and proof of their illness (Playle, Keeley 1998). This attitude clearly denies the legitimacy of patient autonomy and may lead to patients’ being forced into compliance under the Mental Health Act (1983). Szasz (1972) raises the question as to whether patient autonomy exists in mental health care as many informal patients’ may become sectioned if they refuse to comply with treatment, enhancing the paternalistic and power role of the staff.

Even though it is part of the nurses’ role to educate and inform patients about medication (NMC 2002) staff may not be forthcoming or may withhold information regard treatment and medication disempowering patients’ to make autonomous and informed decision (Moore 1995). Patients’ may feel coerced and bullied by the fear that staff will invoke the Mental Health Act (1983) to enforcing or withdrawal treatment if they are not compliant with healthcare advice. Additionally, evidence would suggest that nurses’ modify their patients’ abilities to make autonomous decisions to justify their actions, which may have constrained patient autonomy (Lutzen and Nordin 1994). It is further suggested that nurses’ acted beneficently to coerce patients into making decisions to protect them from making harmful choices. (Svedberg, Hallstrom, Lutzen 2000). On placement, patients’ who were accepted medication were perceived as co-operative. A patient cannot make an informed autonomous decision if they have been persuaded into agreeing to take medication and have not been given the full facts about their medication. Therefore no matter how well meaning the nurses’ intentions may be, they have failed in their duty to respect the patient’s right to autonomy.

Stewart (1987) views non-compliance as being both intentional and unintentional. Rather than make assumptions, if staff understood why the patient does not want to take medication they may see it from the patient’s individual viewpoint. It may be that the medication causes side effects that once discussed, could be remedied by the consultant offering something to counteract the side effects or different medication, or perhaps the patient is just forgetful and so would prefer depot medication. On placement, a patient explained that they had made the autonomous choice not to have their medication because they believed it did not benefit their condition. They may have said this because they were fearful of side effects, delusional or it may be because they were right. Many treatments from the past, which were believed to be beneficial such as purging and bleeding, are now questionable (Trostle 1988). The consultant respected the decision and asked the patient if they would like to try another type of medication or to go without any medication and review how the patient was feeling at the next appointment.

Autonomy and Paternalism
There are occasions when healthcare professionals’ must act against the autonomy of the patient to prevent harm or injury to the patient. If a patient is detained under the Mental Health Act (1983) they may be given treatment against their will, even if they have the capacity to make their own decisions (NMC 2002). Practitioners justify this from a paternalistic approach, explaining that treatment is provided in the best interests of the patient. Garritson and Davis (1983 page 18) describe paternalism as an action “which restricts a person’s liberty justified exclusively by consideration for that person’s own good or welfare and carried out either against his present will or his present commitment”.

On placement, a 17 year old a patient attempted to hang herself but was prevented from doing so by staff. Staff undertook this paternalistic intervention because it was felt that the patient had made an irrational decision due to temporary mental incapacity. Had she been mentally well staff believed she would not have wanted to die. In contrast, Szasz (1983) opposes healthcare professionals’ decisions to act paternalistically and disregard the patients’ autonomy, even if this means the patient may be at risk. Staff may select choices on the behalf of the temporarily incapacitated patient by asking, “what would the patient decision be in normal circumstances?” however, this question will always be based on preconceived assumptions and may not reflect the patients true wishes. Suicide is generally considered an irrational act (Irurita, Irurita, Betancor, Saavedra, Los Santos 1998). The patient’s life may have been so unbearable that her decision to end her life may have been what she had wanted. Staffs’ beliefs, opinions, attitudes and judgements may have been different had the patient been 77 years old rather than 17 years old. This suggests that ageism could also be an element for consideration in terms of how much autonomy a patient may or may not have.

It could be argued that by overriding patient autonomy by forcing patients to take medication against their will under the guidelines of the Mental Health Act (1983) may be detrimental. Non-maleficience means that we ought not to inflict harm intentionally on others. (Beauchamp, Childress 2001) Certain medication which may relieve psychosis, may cause possible irreversible harm to a patient, such as tardive dyskinesia, so this could be seen as violating the principle of non-maleficience (Breeze 1998). On placement, a patient who had never wished to take medication but have been forced to do so under the Mental Health Act (1983) suffered from tardive dyskinesia as a result of prescribed drugs. However, another sectioned patient, forced to accept medication, also had tardive dyskinesia but said that was preferable to them than being psychotically ill. In effect healthcare professionals overridden both patients’ autonomy had resulted in one patient being relieved from psychotic symptoms, both having irreversible side effects and yet both feeling very differently about having their autonomy being challenged, one believing the outcome was good and the other believing the outcome was bad.

Autonomy and Ethical and Moral Theories
Ethical and moral theories are important because without them human life, individual rights and needs may not be valued or respected. The same value of importance applies to healthcare, without ethical and moral worth, patients’ rights and autonomy would not be valued. It is also important to acknowledge that although there are differing moral theories, which approach issues from differing perspectives each theory is concerned with respecting and achieving the common good and they may or may not all arrive at the same conclusion of a situation, but for differing reasons. The following paragraphs will attempt to highlight the experience of patient autonomy via differing theories and the implications for patients in practice.

In theory, all patients should have an equal right to autonomy. Liberal individualism is a rights’ based theory, and actions are valued on respecting the rights of the individual (Beauchamp and Childress 2001). On placement, a patient had his cigarettes rationed otherwise he smoked them all at once and would have no money to buy any more until he received his next payment of income support. This paternalistic intervention did not respect the patients’ right to act autonomy. Some staff justified this, claiming that a rationed amount of cigarettes each day was kinder to the patient than him running out of them and having to wait for a week until the next payment. Whilst patients’ may differ as to how much autonomy they wish to have towards their care, this does not mean they wish others to make decisions for them (Bayne 1998). Some healthcare professionals supported the liberal individualist approach, believing the patient had the right to smoke his cigarettes when he wanted.

Utilitarianism is a consequence based moral theory, also called teleology, whose originators were Jeremy Bentham (1748-1832) and later John Stuart Mill (1806-1873) (Beauchamp and Childress 2001). This theory suggests actions are right or wrong depending on their good or bad consequences, and the best outcome is the one that benefits the maximum amount of people. The NHS is utilitarian as it provides care for all patients at their time of need, not reserving care only for those who can pay for it (Tschudin 1994). It is also paternalistic, valuing patients mental health well being over their right to be autonomous. However, it believes that for patients’ to have autonomy this is a common good as it benefits the maximum amount of people. The consequences of not respecting autonomy could result in moral chaos and unprofessional practice.

Mill (1859) defined autonomy from a utilitarian perspective, as a protection from unwanted interference from others, resulting in the greatest happiness for the greatest number of people. Perhaps Mill would have thought that the patient had the autonomous right to chose when to smoke his cigarettes, but might have suggested that staff explain their concern that he may crave nicotine when his cigarettes had run out. Mill’s (1859) theory is important because it highlights the point that autonomy is more than freedom from interference. It suggests that certain criteria must be in place before a person can act autonomously, such as the full facts of the situation. The individual should make an informed autonomous decision and it should reflect their desires, however Mills (1859) allows for the beneficent and paternalistic intervention of a third party if it is considered necessary.

Patients’ with dementia may have fluctuating levels of mental capacity and as such their ability to act autonomously is of a fluctuating nature and should be respected in relation to the situation and occasion (Adshead 1998). On placement, a patient with dementia had his cigarettes removed as he continuously set fire to his clothing, which meant he had to ask for his cigarettes. It could be argued that staff took a utilitarian rather than liberal individualism approach to patient care as they felt that paternalistic action was required overriding the patient’s autonomy for the benefit of the patient’s own safety.

Kantianism is obligations based moral theory, often called deontology, which suggests that our actions be judged not by their consequences but by whether such actions are morally right or wrong. Kant (1998) denounces paternalism as it benevolently restricts the autonomy of the individual (Beauchamp and Childress 2001). Alternatively, it could be argued that staff were not acting in a paternalistic or anti autonomous manner, instead they had a duty of care (NMC 2002) towards both afore mentioned patients’ and were obliged to keep the first patient from suffering nicotine withdrawal between smoking all his cigarettes and whilst waiting for his next benefit payment and the second patient from setting himself on fire

Communitarianism is a community-based theory (Beauchamp and Childress 2001). In practice, a patient with paranoid schizophrenia wanted to remain at home rather than become a hospital inpatient. Healthcare staff took a communitarian stance believing that the patient and their family would benefit more from the value of the patient being kept at home in safe, familiar family and community environment than by being brought into hospital, as long as the patient agreed to attend a weekly appointment at the inpatient unit. This approach seemed to acknowledge the patient’s autonomous wish to remain at home and yet at the same time it was conditional on the patient agreeing to attend weekly hospital appointments, so restrictions were placed on the patient. Article 8 of the Human Rights Act (1998) protects the individuals’ right to privacy and a home life, defining that interference from authority is acceptable in the interests of the person’s health or morals or for the protection of others. This appears to balance the agreement made between the patient and healthcare staff, viewing it as a win – win outcome for all involved.

However it could be argued that had the patient not agreed to the terms set by healthcare professionals’ he may have been forced to be admitted to hospital, thus raising the question whether the patient had any autonomy in the first place. Government legislation (Department of Health 1990a, 1991, National Service Framework for Mental Health 1999, Reforming The Mental Health Act 2000, The NHS Plan 2000, The National Service Framework 1999) indicates an anti-paternalistic stance by promoting patient autonomy through patient choice and the patient being involved in the decision making and their care, but in contrast the Patients’ In The Community Act (DOH 1996) says that healthcare professionals’ must monitor patients’ in the community deemed at risk of causing harm to themselves or others (Rogers 1996) thus giving power over the patient and their autonomy to the healthcare professional.

In Conclusion
To conclude, this assignment considered whether mental health patients’ could have autonomy in a healthcare setting. Whilst patients have a right to autonomy, it would appear that complex issues including capacity, consent, compliance, paternalism, staff duty, staff beliefs, attitudes, values, judgements, differing ethical approaches and the healthcare environment merely allow patients’ a measurable quantity of autonomy based on legal, ethical and moral restrictions, if this is the case, is this autonomy at all? As a result of this inquiry it would appear that there is no cut and dry answers only a deeper understanding towards the complex issues of patient autonomy.

In Reflection
In reflection, the process of this assignment I have been able to consider my understanding of what autonomy means for patients. Via discussions within the EBL and peer groups, doing the literature search and resources on webct, this has challenged and improved my understanding of patient autonomy and its implications for practice. Groups facilitated by tutors were extremely informative and aided learning however I found the unfacilitated EBL group less interested in discussing ethical aspects that were not on the same topic as the subject they were focussing on. However in my own peer group, we discussed each other’s topics equally. Perhaps this is a moral part of friendships, a willingness in helping each other to learn and succeed. I felt assured that in my peer group information would be shared and discussed enthusiastically to gain insight into ethics. Perhaps having the opportunity to formulate our own peer discussion EBL groups rather than being placed into prearranged groups would have been more desirable. Through peer group discussion I realised that I had been limited in my beliefs and attitudes towards patient autonomy in a practice setting and had not fully understood its implications for patients care. I had not fully considered the restrictions patients may have due to capacity, coercion, fear, staff judgement, nor did I recognise the full implications for patient autonomy in respect of the Mental Health Act (1983).

Through this enquiry, I’ve realised that the process of hospitalisation itself can make patients feel disempowered to act autonomously, for example they are told when it is meal times, smoking times, medication times, visiting times, leave entitlement and this list goes on. During consultant ward visits the patient is placed in a room with up to five healthcare professionals who express their views on how the patient’s care should proceed. This experience must feel over powering and daunting to the patient, making it overwhelmingly difficult for the patient to voice their wishes. This has led me on to consider how valuable advocacy and empowerment is for patients’. At the beginning of this assignment I didn’t really understand the full impact of ethics in relation to patients and healthcare practice, however this has changed and I have become extremely interested in ethical issues as a result and I would like to continue learning more to expand my knowledge base. The overall word limit has proved restrictive and too small to do this subject justice. A larger word limit would have enabled me to give more depth to the issues I’ve discussed, plus looked at other aspects of patient autonomy such as advance directives. Using webct has enabled me to develop my research skills utilising the Internet to source credible information.
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