Parentalism and Paternalism in Mental Health - Coursework Example

Running Head: Parentalism and Paternalism in Mental Health Student’s name Institution Course Professor Date Paternalism can be defined as a policy or practice of treating or governing people in a benevolent yet commonly intrusive manner (Zomorodi & Foley, 2009). The concept of paternalism is ingrained in healthcare, where expert health professionals have traditionally provided advice to the passive patient, who is expected to take this advice unquestioningly or as they are told (Barker, 2011). Paternalistic measures are often used in mental health when dealing with those who have a mental illness, who have a degenerative disease such as Alzheimer's, or who may lack the capacity to make fully rational choices for themselves. Healthcare professionals and other caregivers may act to make a decision for their patients or may prevent the patient from carrying out a decision on the premise that such an action is for that person's own good (Beauchamp & Childress, 2009). The scenario for this essay is drawn from a case study from my placement area in a mental health rehabilitation centre. The mental health consumers have provisions for occasional leaves as part of the rehabilitative process. Besides pharmacologic treatment, the change in a person’s environment is aimed at facilitating one’s distress. However, some of them would use the allocated time to indulge in drug misuse, an act which retards the efforts of recovery. As a result, those leaves are revoked by the registered nurses because of its negative implication on their instituted treatment plans. This restriction has been met by resistance from the affected consumers. The overall goal of all the collaborative efforts by all the partners in rehabilitation is to restore the individual’s well-being as well as the community functioning. In this instance, the nurse is acting in the best interest of the patient’s welfare and in the process attenuating his/her right of autonomy. The significance of the leave is lost if a patient resorts to abuse drugs and alcohol which would otherwise lead to deterioration of mental condition and render the progress ineffectual. Therefore, revoking this privilege will eliminate exposure to contextual cues and access to the drugs thus improving the chances of recovery. The nurse can act benevolently in view of the patient’s condition by making such a decision, not without full explanation of the action (Barker, 2011). This paternalistic gesture is no substitute to collaborative endeavors to empower our clients with a goal of recovery. An understanding of the concept of paternalism provides the tools to reasonably explain the charge of paternalism leveled against a healthcare provider in the medical field or to some governmental and/or institutional policies. It can also explain why certain instances of paternalism are permissible, especially in mental health. Some views have been put forward to explain and justify the normative character of paternalism. According to Butts & Rich (2008), two kinds of paternalism exist in the medical context: soft and hard paternalism. They can be distinguished on the basis of the underlying motivation for a particular act. Soft paternalism entails interference to ensure that only those known to lack sufficient capacity to make fully informed and voluntary decisions against an impending harmful action or omission. It is not motivated by the need to avoid the negative ramifications of their own decisions. The concern here is whether or not the decision is in truth his/hers. If the act is attributable to a foreign will, it is probable that it is due to external threats or coercion. This external influence amount to coercion gives the basis for the argument that paternalism is generally wrong. More coercive actions can be less objectionably paternalistic, and vice versa. Hard paternalism is a term used to describe “actions that prevent major harms or provide major benefits while only trivially disrespecting autonomy (and that) have a plausible paternalistic role” (Beauchamp & Childress, 2009, p. 214). In contrast to soft paternalism, hard paternalism involves interference to make a decision even with informed, voluntary and autonomous refusal for intervention in absence of competing moral factors. It is motivated by beneficence and thus taking a strong position on what is best for the person to avoid self-harming decisions. In this instance, individuals with impaired capacities suffer diminished autonomy. It can be argued here that paternalism is therefore a response to this incapacity with an anticipated benefit to the restricted individual. This implies that the acts of paternalism express the idea that the actor knows better than the person acted upon because the other party is not capable of making good judgments for him or herself. The objective justification for the action will be that someone is not able to judge what is best for him or her. However, as with individual actions, paternalistic actions can have implicit, complex, or unintended meanings. This calls for every nurse to understand “the thin line between advocacy and paternalism” (Zomorodi & Foley, 2009). Mental health elicits a unique challenge to the healthcare providers since the capacity of their patients to make a decision is in question. The etiology of this impairment is unclear in most cases except in some cases following substance abuse or general medical conditions. In all the cases, the ability to make decisions or judgment is hindered. Consequently, the main issue that will arise lies on the question whether or when to intervene. When, if ever, do we step in and make decisions for them? Mental health nurses are guided by ethical principles and legal framework in their routine provision of services to the patients. Based upon the health care professional’s belief about what is in the best interest of the patient, he/she chooses to reveal or withhold the information regarding the diagnosis, therapy and prognosis of the patient (Butts, & Rich, 2008). This paternalistic approach invokes a conflict between the ethical principles of autonomy and beneficence. Therefore, it is imperative that we respect their wishes to the extent that they are still autonomous and make decisions that reflect the patients' current values with a desire to positively help them. The problem of paternalism is often expressed in terms of a conflict between the principles of autonomy and beneficence (Hope, Savulescu and Hendrick, 2008), as alluded earlier. Though the actions are intended for the patient’s best interests, constant evaluation of these interests in view of the current condition of the patient fosters a better understanding of the patient’s views thus better care. It is therefore invaluable to observe the ethical principles in order to preserve the nurse-patient relationship. Paternalism is problematic because the definition of a patient’s best interests used by a paternalistic approach is too narrow. Mill, in his defense of libertarian principles, holds that it is because ‘such best interests are not determined by the medical facts alone’ (Hope et al, 2008). This implies that the patient’s views and their beliefs matter. In addition, the principle of autonomy requires that the respect of the patient's right to self-determine a course of action is upheld. If a patient lacks capacity for such a decision and has an advance directive, the person who has the durable power of attorney can make the decision, as outlined in Mental Capacity Act (2005). Patients with mental health issues are often at a disadvantage especially if a gap exists between them and their care givers in terms of the details of their condition, the treatment options and even their education, which essentially makes them vulnerable.  Health professionals should be mindful of this and seek to redress the power imbalances between themselves and patients (Warren, 2010). Ethical principles form the basis of many laws. Since the inception of International Council of Nurses (ICN) in 1899, codes and laws have been enacted to ensure that the respect accorded to these principles is maintained. This relationship between ethics and legislation is paramount in the general welfare of our patients. This has seen that legislative frameworks, codes, guidelines and competency standards are set up to protect the relative vulnerability towards paternalistic approaches when dealing with patients’ needs (NMBA, 2008). The usefulness of the universal ethical principles and theories cannot be overemphasized for they have withstood the test of time (Butts & Rich, 2008). Ethical codes that have been established largely serve as systematic guidelines for shaping ethical behavior of all personnel in the nursing practice. They seek to answer the normative questions of what beliefs and values should be morally accepted. However, they are never short of ambiguity and conflict. It is for this reason that there are proponents of virtue ethics which emphasizes on a person’s character rather than the rules, principles and laws (Beauchamp & Childress, 2001). For instance, the Code of Ethics for Nurses in Australia enshrines various values that underscore the commitment in the nursing profession to respect, promote, protect and uphold the fundamental rights of people who are both recipients and providers of nursing and healthcare. This fosters that ensures quality healthcare delivery. Moreover, the Code of Professional Conduct act in tandem with the Code of Ethics to provide a legal framework for professional accountability in the nursing practice in areas of education, clinical management and research. Standards outlined by Australian nursing and Midwifery Council, the National Competency Standards or the Nurse Practitioner, serve to define the role and scope of what is to be expected of a nurse. Certain level of knowledge and skillset, as part of their qualification, would allow one to conduct their duties professionally thus ensuring safe and competent practice. It is from these premises that the performance of students and nurse practitioners are assessed in order to obtain or renew their license to practice. The input to general healthcare of our patients by these regulatory standards cannot be overlooked because the existence the nurse-patient relationship can be ascribed to it. Other resourceful guidelines contain a framework for decision-making and provide a means of identifying and differentiating between professional and personal relationships, as well as stipulating the requirements, endorsement and re-entry to professional nursing practice. Provisions for modifiable conduct of a practicing nurse have been established to protect the patient and promote safe and quality in healthcare. Conversely, nurses are protected by professional indemnity insurance. It provides enrolled nurses, registered nurses and nurse practitioners with insurance from civil liability. This insurance generally includes cover for legal claims for compensation and associated expenses arising from the enrolled nurse, registered nurse or nurse practitioner’s practice. Mental health can invoke grave confidentiality concerns which usually have legislative implications. Effective treatment requires accurate information which in turn demands trust in handling it from the healthcare provider (Crigger, 2002). Patients are most likely to provide this information when they are not worried about public exposure. Failure to observe the principle of fidelity obscures the good intentions one might have. Every nurse practitioner has a professional and legal responsibility to respect and protect the confidentiality of their patients. It is a professional responsibility because the standards set are for every practitioner in order to protect the public. It is a legal responsibility because the law dictates that professionals have a duty to protect the confidentiality of the people they have a professional responsibility with. To this respect, many pieces of legislation have been established. They include, among others, the Data Protection Act (1998), the Mental Capacity Act (2005) and the Freedom of Information Act (2000). There are exceptions to disclosing the personal health information. It is only lawful and ethical to disclose them if the individual has freely given an informed consent to the information being passed on. Consent to disclosure of confidential information may be explicit or implied. Disclosure without consent is also possible in some exceptional circumstances that justify overruling the right of an individual to confidentiality in order to serve a broader social concern (public interest) or if required by law. A risk or breach of confidentiality either due to individual behavior or as a result of organizational systems or procedures should be reported to relevant authorities to ensure the people under care are protected. It is clear that the practice demands enormous responsibility from an individual nurse, the institution involved and at the national level no wonder meaningful efforts are constantly enlisted to the practice through these policies and recommendations. This attempt to safeguard the time-honored practice with minimal infringement of the covenant between both parties. However, these professional codes, standards and guidelines, do serve a useful purpose in providing direction to healthcare professionals, nurses included, although, ultimately, one must remember that codes do not eliminate moral dilemmas and are of no use without professionals who are motivated and committed to act morally. Benner, when speaking of the nurse’s role in working for social justice, holds that “each of us and each nursing organization” must “breathe life into the code by taking individual and collective action” for them to have meaning (Fowler & Benner, 2001). Learning from this professional issue, and from the experience I had in my clinical placement, I will derive some recommendations for practice. Firstly, one is required to uphold the ethical principles and codes. Our approach to care should be thoughtful to avoid illegitimate intrusion of autonomy. The fact that they have some autonomy doesn't mean we shouldn't make decisions for them. We should respect their wishes to the extent that they are still autonomous and make decisions that reflect the patients' current values as well. Their liberty is only good if they pose no harm to themselves or others. In addition, it is important to understand that service users expect the health and care professionals involved in their care or who have access to information about them to protect their confidentiality at all times. This public confidence should maintained by exercising this principle but acknowledging a few exceptions where it must be broken for the better good. A nurse is also obligated to observe exemplary standards in patient care since they are responsible and accountable of the decisions they make. The decision frameworks aid to reduce dilemmas and provide justification to those decisions. Moreover, nurses and other healthcare providers should act as a team in learning and practice (Sargent, 2008) for the good of the patient. Each one is responsible and the concerted effort is to improve the general outcome. Despite competing arguments, it can be concluded that whilst there may be some situations when the use of paternalism can be justified in mental health care, it should be exercised with caution. It should not always be assumed that the patient is wrong or irrational whenever disagreement arises between nurse and patient on what is considered to be in the patient's best interests (Jackson, 2009). Wherever possible, patient’s autonomy should be respected to allow a patient-centred decision making approach. This empowerment of patients provides a means of redressing the often unequal imbalance practiced in the old paternalistic attitude in which patients were kept in virtual ignorance (Campbell, Gillet and Jones, 2005). REFERENCES Barker, P. & Buchanan-Barker, P. 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