Autonomy Vs. Paternalism In Mental Health Treatment

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 
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