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
REFERENCE
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
Commission on Quality of Care for the Mentally Disabled. A Pamphlet.
What is
The Commission? New York:
Commission on Quality of Care for the Mentally Disabled.
Corey, G., Corey,
M.S., Callanan, P. (1993). Issues and
Ethics in the Helping Professions. (4th
ed.). California: Brook/Cole Publishing Co.
Penny, D.J.
(1994). Choice, common sense, and
responsibility: the systems obligations to
recipients.
In C. J Sundram (Ed.), Choice & Responsibility (pp. 29-32). New
York: NYS
Commission on Quality of Care for the
Mentally Disabled.
Rooney, R.
(1992). The ethical foundation for work
with involuntary clients. Strategies for
Work with Involuntary Clients. (pp. 53-74).
New York: Columbia University Press.
Sundram, C.J.
(1994). A framework of thinking about
choice and responsibility. In C. J.
Sundram (Ed.), Choice & Responsibility
(pp. 3-16). New York: NYS Commission on
Quality of Care for the Mentally Disabled.
Surles, R.C.
(1994). Free choice, informed choice,
and dangerous choices. In C.J.
Sundram
(Ed.), Choice & Responsibility (pp.
17-24). New York: NYS Commission on Quality of Care
for the Mentally Disabled.
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