Seclusion & Restraint II
Michael A. Gillette, Ph.D.

I have often argued that the most profitable approach to issues in applied ethics, like those encountered in the medical setting, is to argue by analogy. It is important to understand the theoretical underpinnings of our chosen positions, but is equally or perhaps more important to be able to place our moral judgments into a consistent and coherent set of attitudes. Once we have a basic set of values and a selection of intuitively clear cases to guide us, it becomes easier to evaluate new problems as they arise. I believe that this is true of the topic introduced last month - that of seclusion and restraint.

Last month I claimed that the ethical issues surrounding the use of seclusion and restraint can be classified into four groups and approached in two ways. The four ethical classes of concern were 1) direct harm to self, 2) direct harm to others, 3) indirect harm to self, and 4) indirect harm to others. The two approaches to these four classes are paternalism and distributive justice.

The examples given for the categories of direct and indirect harm to self were, respectively, a client who engages in head banging behavior and a client who routinely rolls out of bed. The examples given for direct and indirect harm to others were, respectively, the overtly violent client and the client who utilizes resources to the point where a scarcity, and subsequent diminishment in the quality of care, is created for other clients in the same living area.

I believe that by identifying the paternalistic approach as appropriate for both types of harm-to-self cases, and by identifying distributive justice as appropriate for dealing with the harm-to-others cases, that clear analogues to these situations can be identified and the ethical issues involved can be resolved.

As outlined in earlier newsletters, there is a rather settled opinion in both the legal and philosophical literature regarding paternalistic intervention. Over the years, the approach to paternalism that was based on a belief in an objective standard of 'best interest' has been replaced by an understanding of a client's good that is far more subjective and patient-centered. The theoretical shift is based on the notion that what is of benefit to one person may not be of benefit to another, because we all have unique sets of values. Furthermore, as autonomous individuals, we all have a right to order our own lives according to our own set of values. You ought to be restricted from governing my life, and I ought to be restricted from governing yours.

While this emphasis on autonomy is central to our understanding of human rights, it does not rule-out paternalism altogether. In order for you to have a right to govern your own life, you must be capable of making autonomous decisions. In other words, since your right to make your own decisions is based on your autonomy, autonomy is a

necessary condition to having the right to make your own choices. To the degree that you lose your autonomy, you lose your right to make your own decisions.

A loss of autonomy, however, is not sufficient grounds for me to interfere in your life. Nor is it justification for my interference in any way that I see fit. A value placed on autonomy creates a requirement on my part to respect your ability to make autonomous decisions to the extent that you are able, and to help you approximate your autonomous will when it is restricted.

According to this 'substituted judgment' approach to autonomy, when your lack of ability to make your own choices creates a situation in which you act contrary to your own best interest (based on your values and not mine), I have a responsibility to help create for you a state of affairs that you would want if only you could make decisions based on your own values.

This general approach to paternalistic decision making helps us in considering the use of seclusion and restraints for individuals who are either directly or indirectly self-injurious. According to this way of thinking, it would be permissible to utilize seclusion or restraint when it is reasonable to assume that the patient in question has lost (or has never developed) an ability to make autonomous decisions

regarding the issues at hand, and when employing seclusion or restraint would actually help to create an outcome that is consistent with the client's values. In other words, the use of seclusion and restraint is justified whenever their use would help to satisfy a client's values rather than over-rule them.

There still may be gray areas in paternalistic decisions regarding seclusion and restraint, but those gray areas should be empirical and not theoretical. I can imagine a situation in which it is difficult to know the content of a client's values, or a circumstance in which a client fails to have any relevant values at all. Still, in such situations it would become the duty of the treatment team and involved family or loved-ones to identify what the client enjoys in life, and to determine whether the use of seclusion or restraint is likely to increase or limit the opportunity for such experiences. Once this is determined, the moral aspects of the situation will be resolved even if practical issues remain

I believe that of the two remaining classes of cases under consideration, direct harm to others is the easy one to resolve. The last category, indirect harm to others, will be more difficult to discuss. The discussion of both categories, however, will have to wait until next month.