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