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