Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0THE PSYCHIATRIST IN THE NURSING HOME 715Patient Autonomy vs. Duty of Care—the Old Age Psychiatrist’s DilemmaAdrian TreloarMemorial Hospital, London, UKThe twentieth century has seen huge transitions in medical andlegal practice based upon changes in the philosophy underpinningthe way in which doctors relate to patients. At its lowest points,the Nazi programmes of extermination and forced sterilization inthe USA, Sweden and elsewhere have demonstrated the capacityof doctors for abuse of their patients 1 . In the UK poor-qualityprocedures around consent, and scandals such as patients beingcharged by carers for their weekly bath and other ‘‘privileges’’,have shown just how easy it is for the vulnerable to be abused.Arising from this has been a philosophical, legal and medicaltrend towards self-determination and autonomy. Advance directiveshave been promoted as a solution to the loss of autonomy.They have, however, been shown to have limitations. Indeed, onestudy found that the entire health gain from cardiac rehabilitationprogrammes was neutralized because patients in the study signedadvance directives 2 .Old age psychiatry must, if it is honest, admit that it viewsautonomy as a limited concept. The use of legal tools such as theUK Mental Health Act to detain mentally ill patients, along withthe widespread housing of demented people behind locked doors,even without a formal detention order 3 , shows that autonomydoes not rule undisputed. There is also evidence that the practiceof administering medication covertly within foodstuffs is widespreadin the UK 4 . How can we justify such acts? In a landmarkjudgement, the UK Law Lords held that the mentally incapacitatedcould be detained and treated in their best interests becauseit was their illness that primarily removed their autonomy and notthe fact of their detention 5 . Doctors and others may thereforetreat the mentally incapacitated against their wishes when thepatients themselves will clearly benefit from such treatment.This shows that old age psychiatrists have an inescapable andawesome responsibility to balance the principles of autonomy andgood clinical care when they are in opposition. This balancing actmust be open to scrutiny and requires that good clinical care ofthe patient is the focus. The twentieth century was too heavilylittered with examples of patients’ needs coming second to theintentions of others for it to be otherwise. In essence, to betrustworthy, doctors can never intend harm.REFERENCES1. Kevles DJ. Eugenics and human rights. Br Med J 319: 435–8.2. Treloar AJ. Advance directives: limitations upon their applicability inelderly care. Int J Geriat Psychiat 1999; 14: 1039–43.3. Shah A, Dickenson D. The Bournewood judgement and itsimplications for health and social services. J Roy Soc Med 1998; 91:349–51.4. Valmana A, Rutherford J. Over a third of psychiatrists had given adrug surreptitiously or lied about a drug. Br Med J 1997; 314: 300.5. House of Lords. R v. Bournewood Community and Mental HealthNHS Trust ex part L. Judgement, 25 June 1998.