173

CLINICAL ETHICS

J Med Ethics: first published as 10.1136/jme.28.3.173 on 1 June 2002. Downloaded from http://jme.bmj.com/ on 14 March 2019 by guest. Protected by copyright.
Everyday ethics in an acute psychiatric unit
V J Grant, J Briscoe
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See end of article for J Med Ethics 2002;28:173–176

authors’ affiliations
.......................
Correspondence to:
V J Grant, Department of
Health Psychology, Faculty
of Medical and Health
Sciences, University of
Auckland, Private Bag
92019, Auckland, New
Zealand;
The paper begins with a brief statement about the centrality of autonomy or self governance as a core
[email protected] ethical value in the interaction between health care worker and patient. Then there are three stories
describing everyday interactions in an acute psychiatric unit. These are used to help unravel ethical
Revised version received issues relating to patient autonomy. Each story is analysed for its ethical components by describing the
27 December 2001
Accepted for publication protagonists’ different perspectives, and their reactions to the events. Attention is also paid to
16 January 2002 institutional policy. Suggestions are made for small changes in both staff behaviour and institutional
....................... procedures. Such changes could enhance rather than diminish patient autonomy.

W
ithin contemporary medical ethics recognition of the way back to self governance gradually reappears as medi-
principle of self governance or respect for autonomy cation and other treatments begin to be effective in assuaging
has altered the nature of interactions between their illness. In general these first signs of a re-emergence of
patients and health professionals in all sectors of the health the capability to act autonomously appear in the context of
system. Psychiatry is no exception. In recognition of the new interactions with other people and, as luck would have it, it is
emphasis, one of the major theoretical changes instituted in in this very context, the everyday social interchange between
the care of the mentally ill has been one of culture: earlier staff members and patients, that the capacity for self govern-
regimes based on containment have been replaced by systems ance may re-emerge. Although this applies to everyone recov-
designed to promote recovery. ering from a severe illness, for people recovering from an epi-
Psychiatry has also provided the context for several high sode of psychiatric illness it is an irreplaceable pathway, and
profile ethical issues in the application of the principles of the ability of staff to recognise, respect, and enhance the
respect for autonomy. There are, for example, problems patient’s role in these interactions is likely to comprise a sub-
surrounding informed consent for patients with impaired stantial part of the therapeutic environment.
autonomy, issues involving compulsory assessment and treat- Thus the core of ethical behaviour between staff and
ment, and worries about contraception for those chronically patients may reside in the seeming minutiae of small social
impaired in their competence. exchanges. Fine-tuning the relationship between health
For many patients with a mental disorder, however, there is worker and patient has become a focus of interest. Notwith-
a more fundamental aspect to autonomy. The very nature of standing the comparative value of the “ethically exotic case”
the illness threatens the sense of self. Therefore, since patients Veatch points out that this new sensitivity has shown us that
suffering from mental illness often lack the capacity for self we must now “be aware of the value dimensions of even . . .
governance, working towards the restoration of autonomy
routine medical choices”.3
becomes a core part of treatment and rehabilitation. To take
Teachers of medical ethics have made similar observations.
this into account in the delivery of health care services, it is
For example, Glick noted that whereas the media usually cover
now recognised that: “Relationships, environments, institu-
the “Brave New World dilemmas”, it is the “prosaic day-to-day
tional structures, and cultural values can support or detract
interactions with patients which are far more pervasive and
from the possibilities for self-preservation, a sense of
well-being, and the maintenance of self ”.1 This goal appears to important”.4 Thus, it may be argued, the moral aspect of the
have required a reorientation of the whole enterprise of caring task applies not just to the big issues, but to every interaction
for the mentally ill. within the caring framework and both patients and health
Where the potential for patient self governance looks to be workers have responsibilities for its legitimacy and authentic-
impaired on a more permanent basis, some have suggested ity.
that small forays into decision making in relatively unimpor- Given their importance, how can new understandings of
tant areas may be all that can reasonably be done. For exam- patient autonomy be introduced into the daily exchanges of
ple, Beauchamp and Childress observed of the chronically ill: an acute psychiatric unit? It is not enough to say there should
“Some patients in mental institutions who are generally be improved relationships between patients and health work-
unable to care for themselves and have been declared legally ers in these settings—there should be, but exactly which
incompetent may still be able to make autonomous choices aspect of these relationships is it that needs attention? This is
such as stating preferences for meals and making phone calls not about being polite, important though that is; it is about
to acquaintances”.2 In such situations staff act with respect acquiring and utilising a deep understanding of the patient’s
towards their patients, even though it is unlikely that the re-emerging needs for self governance.
interactions between them will ever be of the same quality as
those that occur between two autonomous people. THE STORIES
For patients recovering from an acute episode of psychiatric Analysis of the following three stories involves an attempt to
illness, however, the situation is different. For them, the path- unravel the subtleties and complexities of ordinary, everyday

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174 Grant, Briscoe

interactions between patients and staff in an acute mental hazy, but his awareness and knowledge of his current needs
health unit. All the patients in these stories had experienced a was clear. He needed to do something physical, and he needed
recent episode of acute mental illness. All the staff members someone to talk to. Since the acute phase of his illness had

J Med Ethics: first published as 10.1136/jme.28.3.173 on 1 June 2002. Downloaded from http://jme.bmj.com/ on 14 March 2019 by guest. Protected by copyright.
were fully trained and experienced in their respective fields. been controlled, he was experiencing a drive towards
Neither the motivation of the staff to help, nor the patients to re-instating his capacity for self governance.
be helped, is at issue here. All were working towards a But Ron was disadvantaged in his quest for activity and
common goal, namely the patients’ recovery from mental social interaction because he was ignorant of the complex
illness. organisational details surrounding his care. He was unaware
Although fictitious, the stories are grounded in observation that several doctors had been involved with his admission. He
of day-to-day events and situations found in acute psychiatric had been told he was assigned a primary nurse and a duty
units. The incidents were assessed for typicality by asking rep- nurse. But he had no way of knowing that neither the nurse
resentatives of nursing staff, psychiatrists and consumers of who welcomed him on to the ward yesterday, nor the nurse
acute mental health services to rate each story on a scale from who administered his medication this morning was “his”
one to five (one being “this would never occur” and five being nurse. He had no idea of the institution’s rules and guidelines
“this sort of incident is common”). Story one, “Someone to for the care and safety of patients in an acute psychiatric unit.
talk to”, had a mean rating of 4.6; the other two stories each Staff knew that Ron had suffered a major depressive
had a mean rating of 4.0. episode and had expressed suicidal ideation. He had been
given a new antidepressant drug which appeared to be effec-
Story one: Someone to talk to tive. Both nurse and doctor were pleased to see Ron cheerful
and taking the initiative. Later, the doctor experienced mild
Ron is bored. He feels restless and would love to go to irritation that other members of staff—nurse, occupational
the gymnasium for a work-out. He has been for a short therapist or physiotherapist—had not been able to offer Ron a
walk with the occupational therapist this morning but the more therapeutic environment. He himself was doing as much
group walked very slowly. The physiotherapist is busy as he could in organising the drug trial, monitoring its effects
giving a relaxation class. and writing a paper on the results, work which could result in
many more patients benefiting from the new drug he had
Ron’s doctor walks past. “Hello doctor, can I go out for given Ron.
a walk?” The nurse completed her report-writing but felt anxious
that Ron might have decided to go for a walk anyway. She was
“Talk to your nurse, Ron. I’m off to a meeting,” answers relieved to see him chatting to the soft drinks vendor and
the doctor. pleased that he had complied with the restrictions placed
upon him without causing more difficulty.
Ron has no idea who his nurse is today. In the intensive
care unit he did. They would introduce themselves each Story two: My name is Mr Craig
shift. In fact they were always around, never letting you
out of their sight. Thomas Craig sits by himself in the lounge of the acute
unit. He finds it impossible to relate to any of the staff or
He walks up to the nursing station. Half a dozen nurses patients around him. He is 63 years old and feels as
are sitting in the office, laughing and chatting. He knocks lonely here amidst the bustle of the unit as he did sitting
on the locked door. The nurses continue chatting. He at home alone. Since the sudden death of his wife 14
knocks again and one of the nurses opens the sliding months ago it seems there is no one who understands
window. “Yes, Ron, what can we do for you?” “Who is him. Here he is surrounded by people not much older
my nurse?” asks Ron. “I am your nurse today” explains than his grandchildren. When he asked to be taken out
the nurse at the window. “Can I go out for a walk?” “Let of the “young persons’ ward” it was explained to him
me check your leave status,” she says and turns to read that he was not yet old enough for the psychogeriatric
the white board. “Oh, you are only permitted escorted unit. At least he and the staff agreed on one thing.
leave. I should have asked the doctor to change that this
morning. Never mind, you will probably be able to go Most of the time he finds it difficult to communicate with
out tomorrow. Sorry I can’t go with you. I have this report the scruffy, strangely clad patients and staff. Indeed if it
to write,” she says, indicating the open file in front of her. were not for their name badges, he could not distinguish
one from the other. They are having trouble communicat-
Ron walks slowly to the smokers’ room. Maybe he’ll ing with him too. For example it is years since anyone
cadge a cigarette off one of the patients there. He’ll get has called him Tom. Even his late wife had called him
a can of Coke too. The vending machine operator is busy Thomas. Having spent forty years of his life teaching,
replacing stock. “G’day mate,” he says cheerfully. “You twenty of them as a principal, he was accustomed to
wanna drink?” “Yeah,” says Ron, “got nothing else to being addressed as Mr Craig or “Sir”.
do.” “Must be boring in this place. Wanna give me a
hand? You look like a strong bloke and I’ve got to bring This morning, a nurse looking no older than the pupils he
the cartons of drink in from the foyer”. “Sure, I miss my used to teach, and wearing a nose stud which would
work-outs at the gym.” The two walk off down the corri- never have been allowed at his school, dared to call him
dor together, chatting about their body-building pro- “Tommy”. It was the last straw. His whole world had
grammes. been turned upside down. His wife had understood the
value of good manners, discipline and good grooming,
Ethical analysis of the stories calls first for increased but she was no longer available to commiserate with
understanding of both staff and patient perspectives. At the him. No wonder he felt worthless.
level of personal interaction, Ron experienced dissatisfaction
with staff, based on his interior knowledge of what would help After living on his own for 14 months, Mr Craig now
restore his normality. His memory of the last few days was found himself living 24 hours a day with people with whom he

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Everyday ethics in an acute psychiatric unit 175

had almost nothing in common. He shared a room with a From the staff point of view, requests for weekend leave
much younger man. He sat at the dining room table with have been incorporated into the weekly meeting for reasons of
strangers. Even if he had been well, this situation would have efficiency as well as a means of assessing a patient’s progress.

J Med Ethics: first published as 10.1136/jme.28.3.173 on 1 June 2002. Downloaded from http://jme.bmj.com/ on 14 March 2019 by guest. Protected by copyright.
presented great difficulties for him. Arranging the leave can be time-consuming because
He had little knowledge of modern psychiatry. His concept caregivers need to be contacted, medication administered, and
of a nurse still included a smart uniform, efficiency, and limits set. Furthermore, Nancy was unaware of the extent to
respect for patients. He had no faith in any of the staff except which granting weekend leave is dependent on the doctors’
the consultant psychiatrist who, although much younger, and nurses’ assessment of her recovery. Staff are responsible
treated him with dignity, and called him “Mr Craig”. Unfortu- for ensuring that safety is not compromised when limits on
nately he was seeing his psychiatrist only briefly and patients’ freedom are gradually removed.
infrequently.
Nursing staff recognised some of Mr Craig’s difficulty, but DISCUSSION
were not prepared to change their “democratic” style for the All the stories illustrate ethical issues at both the interpersonal
sake of one patient. They did think he might be happier with and the institutional level. At the interpersonal level, each of
older people, but were told he did not meet the admission cri- the patients was acting authentically, either consciously or
teria for the psychogeriatric unit. There were no alternatives in subconsciously, aware of their therapeutic needs. From time to
the rather cramped, utilitarian unit for a more thoughtful time during the day, all needed a few minutes of a particular
allocation of room-mates. Besides, patients generally re- kind of interaction with a health professional. Ron needed
mained in the acute unit for only a few days or weeks at most. interactions that helped him in the task of re-assembling his
normal self. Mr Craig needed interactions that acknowledged
Story three: Weekend leave his background and culture. Nancy needed brief, gentle, reas-
suring conversations with her health professional on a
Nancy is sitting in the lounge of the acute unit along with number of issues, including whether she should apply for
twenty other patients at their “community meeting”. weekend leave. All three patients sought help in one of the few
Although she has been a patient in the unit nearly two ways available to them in an acute psychiatric unit.
weeks this is the first time Nancy has attended these Staff members had a different set of pressures to cope with.
twice-weekly meetings. Up until today Nancy has been Administrative and clerical duties claim time and energy.
unwilling to leave her room except to go to the toilet or Building and maintaining good relations between staff mem-
dining room. She feels uncharacteristically vulnerable bers is also important. Additional pressures come from
and is scared of some of the patients who sometimes attempts to prioritise the various calls on health professionals’
shout loudly. She thinks those patients who whisper time.
together might be talking about her and she has heard The claim that there is insufficient time for interpersonal
others laughing at her. communication in health care is a common one. Yet in a sense
this can be a red herring, since it is more a question of how,
rather than how long. A genuine, empathic, respectful
Nancy has difficulty concentrating on the meeting. A
interaction with a patient need take no longer than a response
patient complains that one of the toilets is blocked and
that lacks these qualities. It would have taken little time to
the occupational therapist explains the day’s programme
annotate the notes: “This patient would feel more comfortable
of activities. Next, the patients leaving at the end of the being addressed as Mr Craig”; and little time for Nancy’s nurse
week are encouraged to say goodbye to the group. to say a word to her before the community meeting, asking if
Nancy can’t wait until she is well enough to be she felt well enough to go out for a couple of hours on Satur-
discharged. She misses her partner who has visited her day afternoon. It is likely to be the quality of the interaction
only once and she knows he will not have fed her cat that counts, more than the quantity. Talking to Ron certainly
properly. would have taken time, but it would not have taken long to
recognise his improvement, say something about it, and
Suddenly she realises that those who would like weekend acknowledge his need. Empathic recognition of his new state
leave are being asked to put up their hands. Timidly could have been helpful even if the opportunity for conversa-
Nancy raises her arm and is relieved when the charge tion was not available.
nurse records her name. Feeling less anxious she spends
the rest of the day planning her weekend. Suggesting changes to policy
All the interactions took place within an institutional setting
The next day, being Friday, Nancy asks her nurse what where there was a legal requirement for staff to follow proce-
time she will be allowed on leave. Her nurse replies that dures and policies. Efficient day-to-day running of an acute
she has been meaning to talk to Nancy since yesterday’s psychiatric unit requires that all staff know, and work within,
the stipulated framework. But these glimpses into patient
community meeting. She is sorry, but her doctor does not
experience suggest that policy decisions influence the extent
think she is well enough to have weekend leave. She
to which patient autonomy is respected. If so, then perhaps
can, if she wishes, go out for a couple of hours tomorrow
committees should spend a little time thinking about the
afternoon with her partner. ethical implications of their decisions. For example, in story
number two, the question of how to address patients had
That night at the meal table Nancy is embarrassed by the already been seen as sufficiently important to require a policy
inquiry of one of her fellow patients: “I thought you were decision but the rigid application of a well-intentioned policy
going out on leave. I saw you asking for it.” appears to have been determined on the grounds of
“efficiency” rather than on a consideration of respect for
Nancy was asked to declare a personal need in a public patient autonomy. Could not health workers take the
forum. As a new patient she was not yet fully aware of the opportunity in their introductory conversations with patients
interest other patients would take in whether she was granted to ascertain how they would like to be addressed? And given
weekend leave. Ex-patients report feeling acute disappoint- the emotional costs to patients, should the policy of assigning
ment and shame when it became known amongst the other all patients to wards on the basis of their chronological age
patients that their application for leave had been turned down. remain unquestioned?

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176 Grant, Briscoe

Story three, “Weekend leave”, raises doubts about a policy more autonomous. Mr Craig’s feeling of being trapped in an
that requires patients to request leave in public. Ethicists alien and inhospitable environment probably hindered the
might ask a range of questions. Who benefits most from this re-emergence of his sense of self and may even have damaged

J Med Ethics: first published as 10.1136/jme.28.3.173 on 1 June 2002. Downloaded from http://jme.bmj.com/ on 14 March 2019 by guest. Protected by copyright.
policy? Does it discriminate unjustly on the grounds of his potential for renewed self governance.
individual differences in personality? Is there a failure of Leaving Nancy to request weekend leave in public without
respect for patient autonomy when staff fail to engage a telling her in advance what to expect, was unlikely to promote
patient individually on matters involving their illness and her recovery. Her experience of disempowerment on the unit
treatment? How can patients be made aware of, and prepared probably did nothing to increase her autonomy or her decision
for, hospital routines? Given their importance, how could making skills.
more opportunities for therapeutic interactions between staff In each story it appears that the patient’s autonomy was
and patients be woven into the day-to-day routines of the undermined rather than enhanced, in spite of the conscien-
unit? It is in such details as these that policy decisions relate tious efforts of well-trained staff. Thus, it could be argued,
to the ethical care of patients in acute psychiatric units. there needs to be more consideration given to bridging the gap
between the subjective “lived experience” of the person with
Suggesting changes in interpersonal interaction the mental illness and the health professional’s world of work
Analysis of day-to-day interaction has generated a need for with all its accumulated array of routines, motivations, and
more practical guidelines for staff. Although most health care moralities. Increasing awareness of, and respect for, patient
workers are now trained in communication skills, it could be autonomy in everyday interactions may help address this
that the underlying principles need revisiting. Happily, good issue. Small adjustments in staff behaviour or in an
sense is available from a variety of sources. First, Toombs has institution’s procedures could result in the promotion of heal-
argued the moral necessity of asking patients: “How is it for ing rather than hurtful interactions.
you?” as the only way to cut through to the immediacy of the In the same way as the physical ability for self care gradu-
patient’s experience.5 Representing many medical theorists, ally reappears in a patient who has had major surgery, so the
Zinn has suggested that empathy is the appropriate tool for ability for self governance gradually returns to patients
bridging the profound difference in experiences between receiving medication or other therapies for the treatment of an
health worker and patient.6 episode of serious mental illness. In recognition of the thera-
Then there is Veatch’s notion of “true partnership” whereby peutic effects of being independent, health care workers in
“two persons of widely different backgrounds, find a point of surgical settings encourage patients to do as much for them-
mutual interest in which each can give to the other while selves as possible before offering assistance. Similarly, for psy-
retaining substantial autonomy”.7 Acknowledging the differ- chiatric patients, the first signs of a return to autonomy may
ences between patient and health professional—differences in be valued as early indicators of the effectiveness of treatment.
ability, knowledge and power, Veatch rejects the idea of physi- There are therefore therapeutic as well as ethical reasons why
cian and patient as equals. He opts instead for mutuality of nurses and other health professionals in psychiatric units
respect. Interactions characterised by such mutuality have might want to enhance their patients’ efforts to regain self
within them the potential for true healing. governance.
Seedhouse has offered a practical solution to the problem of
insufficient time to consider the consequences of routine staff
.....................
behaviours. Acknowledging that many medical interventions
result in temporary diminution (physical or mental) of patient Authors’ affiliations
V J Grant, J Briscoe, Department of Health Psychology, Faculty of
autonomy, he suggests that health workers ask themselves a Medical and Health Sciences, University of Auckland, Auckland, New
key question: “Will these diminishings have the effect of Zealand
increasing the autonomy of the patient in future?”8 Simply by
asking this question, a busy staff member in an acute psychi-
atric unit might be helped to decide on the spot, whether a REFERENCES
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