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Mental illness has a huge stigma in North America according to the survey released by the Canadian Medical Association (CMA, 2008). It comes to the point that it has been described as a societal final frontier of acceptable discrimination. Even today in many societies persons with mental illness are being deprived of their civil rights. The usual reason is to protect the public from dangerous people. The label of mental illness has and continues to be a way to legally lock-up persons that society deems disturbing or troublesome. However, there were changes in mental health legislation (Bill 68, Mental Health Act) based on respect for the person. Reviews of involuntary detainment were mandatory. Persons with a mental illness have the same legal rights as other patients. They could refuse treatment if they had a capacity to make an informed and freely made decision. Discussed Mr. Starson’s case is all about implications of societal values on mental health patient’s treatment, what determines person’s capacity and autonomy. I will attempt to analyze his capacity to direct his treatment and conclude with making suggestions on how this case should have been resolved.
Healthcare professionals have a duty to protect others from harm, whether that means protecting the patient from his delusional thoughts or protecting society from his aggressive actions. Factual evidence of the case states that Mr. Starson was arrested between 1985 and 1998 at least 10 times for mischief, trespassing, harassing phone calls and disturbing the peace, and was charged a dozen times for making death threats (Supreme Court, 2003). His behavior was described as intimidating, threatening and abusive. Mr. Starson’s symptoms were grandiose delusions, paranoia, extreme ambivalence and command hallucinations. His diagnosis included a schizoaffective disorder with symptoms of bipolar disorder and schizophrenia. Treatment should be administered if there is proven benefit and refraining from administering treatment will result in harm. The goal of treatment is to promote humanity and offer patient the ability to function within society despite disease, therefore the focus is on the ends not the means (Thomas, 1990).
According to Kant, a choice can be limited for the good of the patient and the others thus limiting ones autonomy. Autonomy is linked with rationality and an autonomous person is motivated by purely rational principles and has a duty to express his or her autonomy. Individuals have to follow the perfect duty not to harm themselves as well as others. One of the outcomes of this following is to stay in a good health. Mr. Starson, a “once-strapping 6-foot-one man who weighed 175 pounds, was down to 118 pounds in a matter of several weeks after his refusal to eat or drink”(Ottawa Citizen,2005), thus his health was voluntary deteriorating in violation of ones “perfect duty” of an individual. Authorities at the Royal Ottawa Hospital stated that “he was dying, losing all capacity to carry on, and they could not, as a hospital, stand by and watch”. Mr. Starson’s delusional reasoning and lack of appreciation for his current disease state was completely irrational. (Thomas J., 1990)
In order to understand whether or not he had a capacity to direct his treatment we have to know at what point one loses the right to make decisions like this for oneself. It happens at the point where one is too ill to be able to make rational informed decisions. There is a protocol (Bill 68, Mental Health Act) to be followed before anyone can be designated “involuntary” and then such a decision must be reviewed at set intervals. A fundamental principle of medical practice, dating from the time of Hippocrates, is that “doctors must act in the best interests of their patients”. This duty involves balancing respect for the patient’s autonomy with a paternalistic approach to their care, which raises questions about the nature of autonomy and paternalism (Dworkin, 1992). David Hume (1711–1776) in his work “a Treatise of Human Nature” considered that reason alone can never be a motive of an action or decision: ‘it can never oppose passion in the direction of the will’.
Autonomy has been developed and expanded by bioethicists, including Professor Ranaan Gillon, a philosopher and GP. He has defined autonomy as “the capacity to think, decide and act freely and independently”. This definition emphasizes two aspects of autonomy (Gillon, 1994): the capacity or ability of the autonomous person to make independent decisions and to act on those decisions (although limits must be imposed on an individual’s autonomy when it impinges on the autonomy of another person). Autonomous medical choices are generally improved by the physician’s informed input and support. It means that the doctor engages in open communication, informs his patient about therapeutic choices and their odds for success, evaluates and discusses both the patient’s values and his own, and then offers suggestions that reflect both sets of values and experiences. Using Drane’s scale for competency we know that there was high benefit and low risk associated with the proposed treatment and that these treatments were reported as effective for acute bipolar disorder patients. There also were limited alternatives to treatment that would reduce his delusional thoughts. His decision to refuse treatment was made during a time of hysteria, a negative result of his illness, and he held false beliefs about reality, by not accepting his illness or appreciating the consequences of his decision. Given these reasons Mr. Starson satisfied third standard in the scale for competency, determining that it was a reasonable decision for health care professionals to force him to receive treatment (Drane, 1985).
Mr. Starson refused any consent of treatments from prescribed by his physician, because those drug treatments slowed down his thought process (McLachlin, 2003; Mental ill man, 2003). I strongly believe that, even though Mr. Starson did understand the importance of the treatments to address his mental health condition (according to the Supreme Court), but he also knew the side effects and did not want these side effects to happen. He thought his mental problems were better than side effects of medications given to him. He claimed that his values as a patient were not respected.
Forcing treatment upon Mr. Starson was a paternalistic approach to patient treatment and was contrary to one’s autonomy. Thus, it was a complete failure of using the paternalistic model to give appropriate respect to the rights of Mr. Starson to control his body and live.
I think that there is an ethical reasoning for not forcing Mr.Starson to submit to pharmacotherapy. Persons should never be treated as means to an end but rather as an end in itself. We have an obligation not to force our will to another – that means respect ting intrinsic value of all men with dignity. (Moorhouse , 2010). Autonomy means self-determination. This is the right of individuals to make independent decisions concerning their health, life and well being (Yeo, Moorhouse, Khan & Rodney, 2010). Mr. Starson knew the extent of his medical condition. When he was presented with options for medical treatment, he objected. Individuals have to have the capacity and also be able understand the consequences in order to make an informed decision. Mr. Starson clearly understood the consequences for the refusal of medication treatment for his illness. He also provided a rational reason for refusing treatment which is that the medications interfered with is creative thinking as a physicist. He agreed to continue psychotherapy, which showed that he understood and had the capacity to make decisions with regards to his health. Denial of one’s illness is not a sufficient criterion to establish a patient’s incapacity to refuse treatment (Supreme court, 2003). As a result Mr. Starson was found capable of making treatment decisions by the Supreme Court of Canada (Supreme Court, 2003). In order to further respect Mr. Starson’s autonomy, I would consider the Empowerment Model approach to treatment (CMA, 2003) in combination with the recommending medications, in order for Mr. Starson to receive the most all-encompassing method of care on his road to recovery. This includes options such as a Community Treatment Order (CTO) to be implemented in accordance with his taking his medications, even thought there can be a coercion to some extend in the consent to CTO in order to avoid the alternative, admission or remaining in hospital (Moorhouse, 2010). It would also be beneficial for Mr. Starson to consider appointing someone who is clearly involved and concerned with the court’s decision as a substitute decision maker to take his desires into the upmost consideration. This would be a relationship-centered approach leading to enhanced autonomy. Here I would have moved away from the paternalistic approach, integrated the factual details of the medical diagnosis with feelings, values, and interests of the health care team, Mr. Starson and his decision maker through open and careful communication.
At he end, beneficence derived through caring would create mutual caregiver-patient relationship (Woodward VM, 1998), which would balance the respect for Mr. Starson’s autonomy and beneficent guidance based on physician’s clinical expertise and protect the moral integrity of all involved.
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