Unit 10 – From the Asylum to Care in the Community: from Paternalism to Autonomous Decision Making
University of Bristol (UK)
1.1 Topic Description
The lecture is titled ‘From the Asylum to Care in the Community; From Paternalism to Autonomous Decision Making’ and examines the long shift from paternalistic healthcare to the prioritisation of autonomy for patients, alongside the concurrent shift from asylum care to care in the community for the mentally ill. In doing so, I aim to emphasise the ethical issue both with paternalism, and with care in the community approaches. In the course of the lecture I use several historical terms, such as ‘lunatic’, which are now considered offensive. I do so to remain faithful to the historical content of the lecture, as well as to emphasise the changes in medical terminology in regard to the mentally ill.
The lecture is split into four main sections. The first section, ‘Into the Asylum: Paternalistic approaches to Treating the Mentally Ill’ focuses on the development of the county asylum system in Britain from the early nineteenth century, beginning with the developments in thinking about the mind in Enlightenment philosophy. I highlight the therapeutic optimism that accompanied more humane, ‘moral’ treatments in the early nineteenth century, as a way of explaining the enormous increase in the number of patients in asylums over the course of the nineteenth century. Furthermore, I draw links between such care and the control of deviant populations by discussing the way in which asylum care surveilled their patients.
The second section, ‘Hysteria: A Means of Control?’, focuses on the disease hysteria as a means of exerting control over women, and especially over women’s sexuality. After briefly outlining the origins of the understanding of the disease, I focus on its understanding in the nineteenth and twentieth centuries. I show that Charcot’s work on hysteria worked to present hysteria in a transgressive and erotic manner, reinforcing the sexual nature of the disease. However, his attempts at better defining it were not supported by therapeutic progression, with most treatment proscribed in the period being that of the ‘rest cure’, which broke patients’ will in an effort to control them. I then discuss other attempts at curing the disease, focusing especially on the development of psychoanalysis and the ‘talking cure’, which again emphasised the sexual nature of the disease.
The third section, ‘Deinstitutionalisation and Care in the Community’, examines deinstitutionalisation in Britain, and its replacement with care in the community approaches. The section begins by discussing the myriad reasons for the perceived failure of the asylum system, and the new therapies, such as drugs, that worked to offer an alternative to asylum care. I briefly mention the political context of deinstitutionalisation before discussing the changes in provision that were brought about by refocusing care for the mentally ill around social services and local charity. In the final paragraph of the section I discuss the failures of this change, especially due to the neglect that ensued after these initiatives were insufficiently supported and funded by government.
The fourth section, ‘Autonomy in Healthcare: Lasting Power of Attorney and Do Not Attempt Resuscitation Orders’, examines the legal framework that has been built up in order to enable autonomous decisions in healthcare by those with less capacity. It discusses the development of the Mental Capacity Act (2005), especially through the context of the 1995 Law Commission report on mental incapacity. I then discuss the purposes of LPAs and DNARs and the principles through which they operate before introducing some of the criticisms that these orders have encountered. The conclusion briefly summarises the main points of the lecture, emphasising the continued need to develop these frameworks with patients in mind.
The lecture is split into four main sections. The first section, ‘Into the Asylum: Paternalistic approaches to Treating the Mentally Ill’ focuses on the development of the county asylum system in Britain from the early nineteenth century, beginning with the developments in thinking about the mind in Enlightenment philosophy. I highlight the therapeutic optimism that accompanied more humane, ‘moral’ treatments in the early nineteenth century, as a way of explaining the enormous increase in the number of patients in asylums over the course of the nineteenth century. Furthermore, I draw links between such care and the control of deviant populations by discussing the way in which asylum care surveilled their patients.
The second section, ‘Hysteria: A Means of Control?’, focuses on the disease hysteria as a means of exerting control over women, and especially over women’s sexuality. After briefly outlining the origins of the understanding of the disease, I focus on its understanding in the nineteenth and twentieth centuries. I show that Charcot’s work on hysteria worked to present hysteria in a transgressive and erotic manner, reinforcing the sexual nature of the disease. However, his attempts at better defining it were not supported by therapeutic progression, with most treatment proscribed in the period being that of the ‘rest cure’, which broke patients’ will in an effort to control them. I then discuss other attempts at curing the disease, focusing especially on the development of psychoanalysis and the ‘talking cure’, which again emphasised the sexual nature of the disease.
The third section, ‘Deinstitutionalisation and Care in the Community’, examines deinstitutionalisation in Britain, and its replacement with care in the community approaches. The section begins by discussing the myriad reasons for the perceived failure of the asylum system, and the new therapies, such as drugs, that worked to offer an alternative to asylum care. I briefly mention the political context of deinstitutionalisation before discussing the changes in provision that were brought about by refocusing care for the mentally ill around social services and local charity. In the final paragraph of the section I discuss the failures of this change, especially due to the neglect that ensued after these initiatives were insufficiently supported and funded by government.
The fourth section, ‘Autonomy in Healthcare: Lasting Power of Attorney and Do Not Attempt Resuscitation Orders’, examines the legal framework that has been built up in order to enable autonomous decisions in healthcare by those with less capacity. It discusses the development of the Mental Capacity Act (2005), especially through the context of the 1995 Law Commission report on mental incapacity. I then discuss the purposes of LPAs and DNARs and the principles through which they operate before introducing some of the criticisms that these orders have encountered. The conclusion briefly summarises the main points of the lecture, emphasising the continued need to develop these frameworks with patients in mind.
