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Autonomy vs. Safety
February 17, 2011
Autonomy vs. Safety

Posted by Lili Ibara

“Well, and just exactly who put HIM in charge of ME?” a client asks from her hospital bed, shifting her Johnny for better coverage and readjusting her stylish reading glasses. I’ve just told her that the hospital psychiatrist, the one she’s known for all of five hours, has decided she isn’t competent to make her own decisions. “You mean that arrogant man with the terrible puffy hair? But he doesn’t even know the first thing about me!” She sounds almost more baffled that this could have happened to her than angry that it has.
 
Part of me, the part that feels twitchy at the very thought of some psychiatrist deciding what I may and may not do, wants to help her into her tailored jacket so we can make a run for it. I’m sure we could make it to the elevators without anyone noticing and after that I could just drop her off at home. And then? Then, I know from past experience, some crisis would occur, a pot would be left untended, a crucial medication would not be taken, and we’d end up right back here. This client whom I like and admire, this sophisticated confident woman who can still charm an overworked doctor into seeing her hours late for an appointment, has a form of dementia that is devastating her memory and ability to reason. Despite his arguable arrogance and unarguably bad hair, the hospital psychiatrist is right. She can’t make decisions right now. But what gives us the right to decide that?
 
A few weeks ago when we were all home during the big blizzard, my husband and I each separately started to make tea by turning on an empty burner and then wandering out of the kitchen. On various occasions we misplace our wallets, hats, and bags. We leave our keys dangling in the lock overnight. We have even each lost the car: he once caught a ride home from a restaurant, forgetting he'd driven himself there; I have more than once taken the “T” to a different Park-and-Ride station from the one where I boarded.
 
We're both in our 30s, healthy, and employed. We laugh about these mistakes and chalk it up to our over-busyness. We do not start worrying about whether it is safe for us to go it alone, or consider neuropsych evaluations and supportive services, the way I would for a client. Yet these very same mistakes, when they happen to my clients, go into my protective service reports, and fill my worried phone calls to family members. And I don’t mean somewhat similar mistakes; I mean, I’ve actually called someone’s child after finding keys in the door and I’ve fielded calls from children worried because their parents leave the stove on.

In social work school I was taught that respecting client autonomy is right up there at the apex of social work values. Our job as social workers, if we're doing it right, is to help people make the changes they've been wanting to make. It's never our job to parachute into someone's life and make the changes we'd like to see. It's generally okay to point out a positive outcome, like when I encouraged a client who uses an oxygen machine not to smoke; but it wasn’t my place to rush into her house and throw out all the cigarettes. Sure, chucking the cigarettes might have temporarily made her healthier (and lessened the potential for, say, dramatic explosions), but the change would only have lasted as long as it took the RIDE to get her to the corner store. There's also the not insignificant problem that imposing my will on her would likely have made her feel helpless rather than helped. In the end, she gave up smoking on her own and got to feel proud about it - in addition to making me feel safer visiting.

I really do believe in the importance of personal autonomy and the tenet that people feel their best when they have some control over their lives and persons. So deciding to step into someone's life and limit her freedom gives me pause. As social workers, we consider and reconsider particular decisions past the point of utility. We demand that our peers and supervisors and blog readers join us in the rehashing. I don't know if it's anxiety or conscientiousness, but it's what we do.

When I supported that hospital psychiatrist's decision to keep my client hospitalized against her wishes, I was ignoring my client's most fervent, and entirely understandable, desires. But, in my defense, I was trying to do what she would have wanted had she been well enough to understand the risks facing her. I know the dangers of such a string of conditionals. I understand that I can't even know what exactly I would want done in a similar situation. I can only let that twitchy feeling I get now and again remind me of the care to be taken with such decisions. It doesn't mean I shouldn't use my training to make these decisions. They just shouldn't come too easily.

Lili Ibara, LCSW, is a geriatric care manager with JF&CS Your Elder Experts. Lili began her advocacy work in the legal world, working at several legal aid organizations including the ACLU and Texas Rio Grande Legal Aid, and also as a federal appellate law clerk. She enjoys using her advocacy background to help clients successfully navigate through bureaucracies.

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