Humans and non humans can be distinguished based on one major difference that is the presence of intellect. It is the human brain that is valued the most and given utmost importance in the universe of mankind. But this magnitude of importance is justified, when we look at the function of the intellect, and that is the ability to make sound and rational decisions, an element which lower forms of nature lack. All human beings have a specific area in their brain, known as the frontal lobe, which is designated to understand situations and make decisions accordingly which varies for each individual (Bechara, Damasio&Damasio, 2000).Thus that is where the problem arises, as those people who are unable to comprehend and solve matters like others and fulfill their various rolesin society are deemed to be incompetent and are treated insensitively, something which I personally observed during my clinical rotations.
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My patient, Ms. X, was a 35 year old female admitted into a mental institution with bipolar affective disorder and was currently going through a phase of aggression. I observed that when the patient tried to ask questions regarding her treatment, she was ignored and was not answered. Instead, the medications were given forcefully to her without any teaching, which further aggravated her aggressive symptoms. The patient verbalized that she felt that everyone thought she was mental that is why they were not involving her or informing her of anything which made her feel unnoticed and hurt. She further elaborated that at first she felt that she might feel better after admission but after seeing the attitudes of the staff, she was no longer optimistic about her treatment.
In this case, the ethical principle that was applied was of paternalism, but her willingness to learn about the treatment plan was not acknowledged therefore, I feel that the concept of paternalism was misused. Providing medications to a patient is a therapeutic intervention but at the same time coercing the patient into taking the medicationsmay hinder its positive outcome. This paper will try to give insight to the meaning of paternalism, give various view points of paternalism with the help of models, explain paternalism in relation to mental health and give recommendations.
Paternalism involves the assimilation of two basic ethical principles that is autonomy and beneficence. Autonomy means giving patients the rights and responsibility to make their own decision (New Zealand Medical Association, 2008). On the other hand, “Beneficence refers to an action done to benefit others” (Reamer, 2006, p32). According to Dudzinskiand Sullivan (2004, p.479), “Paternalism is defined as the intentional nonacquiescence or intervention in another person’s preferences, desires, or actions with the intention of either avoiding harm or benefiting the person.”Thus we can conclude that paternalism refers to the act in which decisions are taken by a health care professional in order to benefit the patient. Paternalism can be classified in two categories namely individual and social paternalism. Acting against a person for their own good is known as individual paternalism, whereas social paternalism is done for the good of others, such as when the patient may be harmful towards others (Hoyer et al, 2002).Another term to be discussed is coercion, which is “using force or authority to make a person do something against his or her will.” (Collins Compact Dictionary, 2001, p.166). Resultantly we can conclude that coercion is always present to some extent in paternalism (Dudzinski& Sullivan, 2004). Thus in my patient’s case, the concept of individual paternalism was applied. My patient wascoerced to take the medicine, as an act of beneficence, against her wish, that is her autonomy, so that she could gain benefit from her treatment and become stable. However, the staff failed to assess how much decision making capabilities were present in my patient before coercing her, and instead completely overruled her autonomy, which I believe was an incorrect method of applying the concept of paternalism.
From a socio-cultural point of view, most members of society have at one moment or another been coerced into doing something, however, mentally ill patients are one of the most vulnerable groups to be coerced as their unexpected behavior causes disruption in the norms of society, thus they are forced to comply with the authority figures (Geller et al,2006). As a result, such people are shunned and secluded from society due to the stigma being associated with them, especially when one is being coerced as stated by Link, Castille&Stuber (2008, p.416), “when coercion is deployed its consequences can be expected to be uniformly negative for stigma, quality of life, and the ability to function in important social roles”. But on the other hand, mentally ill patients may pose a threat to society and so coercion may become necessary to protect society from harm (Richardson, 2007).Therefore it can be understood that coercion plays a role in molding societies’ perception to the autonomy of a mentally ill patient and their role in society.
According to Kilian et al, (2003), the relationship between the physician and client in psychiatry has always been unequal, meaning that the physician has more control over the patient in terms of decision making regarding admission and treatment plans. However the amount of control of the health care provider varies according to different beliefs and practices. The paternalistic model is one of the models that depict the client physician relation(Emanuel & Emanuel, 1992). This model illustrates that the physician works for the best interest of the patient and therefore has the power to decide and force decisions upon the patient when necessary(Emanuel & Emanuel, 1992). According to this model, the physician is allowed to overlook the patient’s preferences as it is a ‘doctor centered’ model (Emanuel& Emanuel, 1992; Taylor, 2009). The role of the physician in this model is that of a guardian, that is a person who is authorized to make decisions where informed consent is not applicable, thus they are allowed to use coercion on the patient.
The deliberative model reveals another face to the principle of paternalism in which although the physician has a greater control over decision making, contrary to the paternalistic model, it does not completely disregard the opinions and voice of the patient (Emanuel & Emanuel, 1992) According to this model, the physician’s role is that of a friend, that is to convince the patient what is good for them by engaging in conversation keeping the patient’s values and beliefs in mind. (Emanuel & Emanuel, 1992) Although the ultimate result is based on the physician’s decision, the patient is empowered by being allowed to voice their opinions and raise concerns, maintaining the patient’s autonomy to some extent and bridging the gap between the client and physician relationship (Emanuel & Emanuel, 1992) However, coercion can still be used on the patient if the need arises(Emanuel & Emanuel, 1992). In my patient’s scenario, I believe that the paternalistic mode was applied whereas it might have been more beneficial if the deliberative model was applied. Although my patient was mentally ill, she did not completely lack the ability to make decisions, therefore, if my client was allowed to express her concerns over her treatment plan, it would have empowered her and boost her self esteem.
One may wonder that regardless of the patient’s conditions, coercion cannot be validated as it is opposing the patient’s wishes and desires. As a result, in numerous literatures, health care professionals have justified the use of coercive treatment on patients.Firstly justifying paternalism is the “belief that coercion works, meaning that compulsory treatment improves the outcome compared to the outcome with no (coercive) intervention” (Hoyer et al, 2002, p.93). Therefore health care professionals debate that the reason coercion is carried out is due to evidence of a change in the client’s condition. Also, studies have given evidence that those patients who refuse treatment have longer hospitalizations and tend to be sick than others (Heino et al, 2000). Another point of justification is the fact that the physician has more professional knowledge as compared to the patient therefore they can make rationale and nonjudgmental decisions on behalf of the patient (Emanuel& Emanuel, 1992). Another major argument is that in order to be autonomous, a person must have the rationality and capabilities to make decisions, therefore all those clients who do not have rationality cannot be entitled to complete autonomy and so the responsibility goes to the health care professionals instead (Breeze, 1998).
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However, there are some schools of thoughts that have contradicting views regarding paternalistic care in the sense of wellbeing for the client. Researches say that paternalistic care may cause a decrease in the self esteem of an individual, especially for mentally ill patients (Borras et al, 2009). On the other hand, increased self esteem and feeling autonomous may subjectively raise the quality of life for the patient (Bjorkman& Hansson, 2002). Studies have shown that the physician oriented relationship is not helpful as “traditional role relationship prevented the development of self-efficacy expectations and the mobilization of self-help capacities which are necessary for recovery from mental illness” (Kilian et al, 2003). This means that for a person to recover from mental illness, it is important that patient’s should have the internal motivation and the belief that they can bring about a change, a thought that becomes hard to formulate in the minds of people who are coerced into something. Some practioners assume that mentally ill patients are not able to identify that they are being coerced but literature suggests that mentally ill patients not only are able to perceive behaviors of coercion but also report it when required (Moser et al, 2004). Studies further reveal that patients that have been coerced into treatment report less satisfaction as compared to those who have not been coerced (Iversen, Hoyer & Sexton, 2007).According to Kaltiala-Heino et al, (2003), coercing a patient who is not willing to be treated to take antipsychotics maybe distressing for the patient and may even demonstrate that the patient may not have understood the purpose of the medication. Also, it has been researched that perceived coercion may cause a patient to lose trust in the health care system and refrain from approaching for medical help in future events (Stanhope, Marcus & Solomon, 2009). Thus in my patient’s case, although she agreed to the admission at first, the health care provider’s attitude was such that she did not feel that she had any control over any sort of decision making, or she was authorized to any information concerning her treatment. Consequently, she suffered from decreased self-esteem and was having difficulty in trusting the health care workers. The future implication for my patient may be that in the future she may refuse to voluntarily admit herself after being treated the way she was.
According to the discussions above, it is recommended that autonomy should be given to a patient not on the basis of their medical diagnosis, but on the basis of how much capable they are of making decisions by assessing their competencies (Rice, Beck & Stevenson, 1997). In order to promote such types of care, a mental health legislation known as the Mental Capacity Act of 2005 was formulated to defend patients in this matter (Owen, Okai&Hotopf, 2006). This act is based on the fact that a person should be assessed for the level of capacity that is the ability to make morally and legally sound decisions (Owen et al, 2006). The principles of the Mental Capacity Act 2005 include presuming the person to have capacity unless proven otherwise, helping the person to make decisions and working for the best interest of the patient (Ali & Hall, 2009). Before allotting or denying anyone of autonomy, the client should be assessed for the level of capacity so that justice is done (Owen et al, 2006). Moreover, I recommend that institutional policies such as the Mental Capacity Act 2005 should be established to safeguard the rights of patients (Ali & Hall, 2009).
Furthermore, it is necessary that the mentally ill patient should feel to be a part of the decision making team, rather than just an object to be experimented on, in order to develop empowerment in the individual (Chamberlin, 1997). This could be done through counseling sessions and therapies which could help build a therapeutic relation with the client and health care worker through proper communication and treating the patient with respect(Chamberlin, 1997. Health care workers should be aware about the consequences of coercing a patient when it is not required and not use force unless the patient is proven to lack judgment.
This paper discussed the concept of paternalism in relation to mental health in which the underlying principle is favoring beneficence over autonomy in order to protect the patient (Dudzinski& Sullivan,2004). However, it is emphasized that thorough assessment of the patient’s capabilities and involvement of patient in decision making should be encouraged to promote the mental wellbeing of the client and maintain the therapeutic relationship between the health care provider and patient.
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