Quality or Care?

A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

Running Head: Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoos nest.

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoos nest

Kenyon Stanley COMM 614 Dr. Leanne Pupchek December 6, 2010

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

2 Abstract

By analyzing current research on the mentally ill homeless population and the motion picture One flew over the cuckoos nest (1975) through the lens of Health Care Ethics, two troublesome questions arise. Does the United States have quality mental health care facilities? And, are the methods we employ to treat the indigent mentally ill lacking the caring and sensitivity required to ensure a decent quality of life?

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

Introduction

In todays society, homelessness has reached epidemic proportions.

With the

unemployment rate rising to near depression like numbers, substance abuse and the lack of affordable housing, its not surprising that there are so many people on the streets. In addition to the aforementioned social problems, there is one more barrier to self-sufficiency that receives little noticemental illness. In my near decade of working with the homeless, I have noticed that the mentally ill are not treated with the care they deserve. Mentally ill homeless people are not receiving adequate medication, the treatment they receive from shelter providers is impersonal and the agents working at shelters are not trained to provide care for the mentally ill. The lack of medication frequently results in a higher frequency of incidents that often turn violent. I recall one incident where a normally docile homeless client who suffers from paranoid schizophrenia climbed over a counter and assaulted a female staff member for no apparent reason. It took five staff members to pull the client off of the staff member. Unfortunately, both the staff member and the client had to be transported to the hospital to treat wounds sustained in the altercation. The hospitalized employee was later informed that the client was off his

medication and this sort of incident just comes with the territory.

In addition to the lack of sufficient medication, shelter staff are frequently impersonal and desensitized to the individual needs of the clients they serve. Having worked in a shelter, I can affirm that many of the staff portray a distant and uncaring attitude similar to one that can be found at nearly any Department of Motor Vehicle office. This sort of attitude has many

detrimental effects. First, mentally ill or not, people can tell when someone is genuine. If a

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

4 client perceives that a care providers attitude is uncaring, then trust never gets established and it becomes difficult to provide any long term care that would get the client off the streets. Second, mentally ill clients who have a propensity of violence feel disrespected and are more apt to lash out at the uncaring staff. Finally, the mentally ill clients dont feel helped or cared for and thus lose any confidence that they can better their situation. One would think that with all of the medical breakthroughs the western world has made in the last fifty years, the quality of care for the mentally ill would have improved a great deal. Sadly, after analyzing Health Care Ethics, current research, my own experience and the motion picture One flew over the cuckoos nest (1975), it is apparent that the goals of agencies charged with providing care are still perverted actual care takes a back seat to order and control.

One Flew Over The Cuckoos Nest

The 1975 Fantasy Film motion picture One flew over the cuckoos nest was a critical look at mental health care in the 1950s. The main character, Randall McMurphy (played by Jack Nicholson), was a petty criminal who engineered his own committal to a state run mental hospital in the hopes of serving the last thirty days of his sentence away from prison. Not crazy, McMurphy soon realizes that the staff at the hospital dont have the best interest of the patients in mind and instead simply want to control the hospital. No more is this true then in the demeanor of Nurse Ratched (played by Louise Fletcher). While Nurse Ratched speaks in a calm soothing tone and encourages the patients to self-disclose in group therapy sessions, her control over actual care mentality is highlighted in her many dealing with the patients.

In one scene, a suicidal young man named Billy is caught having sex with a woman. Nurse Ratched reminds Billy that she knows his mother and is going to expose his indecent acts

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

5 to his conservative mother. The mentally ill Billy apologizes and begs the nurse not to let his mother know. Nurse Ratched coldly tells Billy, You know I have to tell her, were friends. You did this Billy and your mother is going to be very disappointed in you. The result of the nurses cold response is that Billy, feeling obviously overwhelmed, ends up slicing his wrists, and killing himself because he doesnt want to face his mother. The most disturbing and outright unethical event occurs at the end of the film. The staff, understanding that McMurphy is not insane, realizes that they cant control him. Upset that he will be soon discharged, the staff chooses to perform a double lobotomy on McMurphy leaving him a life-long vegetative state. The care providers in the film chose to exercise an any means necessary attitude to control McMurphyeven at the expense of his mental wellbeing. Ironic considering that the one thing they stole from McMurphy was the one thing they are responsible to protect.

Health Care Ethics

So what is the ethical manner in which agencies charged with providing mental health care should operate? According to Arnett, R.C. J. Fritz &Leanne Bell (2009), care is defined as, a human answer to the call of the Other, a willingness to meet and attend to someone other than oneself (p. 192). In One flew over the cuckoos nest, its apparent that the institution had no regard for the Other. After all, in the final decision regarding McMurphy, the administration chose to lobotomize their patient and meet and attend their own desire of order and control instead of actually getting McMurphy the help he needed. Furthermore, according to R.C. Arnett et al (2009), Health care communication ethics protects and promotes care, human caring for one another, in a professional context and in all contexts where decisions affect the quality of life and, all too often, life itself (p. 199). The above quote explicitly mandates that it is the duty for

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

6 the decision makers of health care to protect the quality of life that their patients are inherently entitled to. In One flew over the cuckoos nest, Nurse Ratched and the other staff didnt care about the patients quality of life, or life itself. Their decisions led to the premature death of Billy and McMurphy.

In the context of the mentally ill homeless, I have seen the lack of concern for the Other far too often. There have been many instances where the shelter staffs concern for their own personal and institutional needs override the needs of the Other. I recall one instance when the shelter received 500 brand new jackets. While the distribution of the jackets would require some careful coordination, the staff could have distributed the coats on that very same cold late fall afternoon. However, the staff refused to distribute the jackets stating that their daily paperwork took precedent over the distribution of coats. The failure to distribute needed resources and the impersonal attitudes was simply an abuse of power utilized by the staff for the purpose of control.

A similar abuse of power regarding the distribution of resources was also highlighted in One flew over the cuckoos nest. Typical of a mid-70s film, a large number of the patients smoked cigarettes. In the beginning of the film, the patients had total possession and control over their cigarettes. However, shortly after the arrival of McMurphy, Nurse Ratched

confiscated the patients cigarettes and distributed them at her leisure. When confronted by the patients, the Nurse simply blew the patients off and attempted to convince them that her decision to confiscate the patients cigarettes was in their best interest, and they couldnt be trusted to keep possession of their property. It was obvious that the Nurse was intoxicated with her position and power. Nurse Ratched made it clear that she would not relinquish her power and

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

7 give the custody and control of the cigarettes back to the patients. While the patients realized that they had no power, none of the patients believed her excuse and their resistance towards the establishment continued to increase. While all the patients were white men, it was apparent that they were being punished for failing to meet the cultural values of the time instead of being treated for their mental illness. The characters in One flew over the cuckoos nest was in the midst of a social reconstruction.

E. Young (2009) conducted a qualitative analysis of four individuals stories highlighting the detrimental impact that cultural values have in effectively treating mental illness. Young examines how each individual was forced to deal with the guilt and shame that arose when their mentally ill condition left them unable meet the cultural expectation of society. Furthermore, Young highlights how superimposing cultural values and expectations on mentally ill subjects made the diagnosis and treatment more difficult.

Youngs report focuses on the clinical diagnosis of depression. For many years, depression was not taken seriously in society. Many people believed (and still believe) that people diagnosed with depression should simply suck it up, pull up their boot straps and take responsibility. Depression is a mental illness and a serious problem with the homeless population. Depression leads to suicidal thoughts, fatigue and many other factors which can render a homeless individual simply incapable of appropriately navigating him or herself to a life of self-sufficiency. Youngs report highlights the dysfunctional sense making methods that mentally ill subjects employ while engaging in narrative discourse. After analyzing One flew over the cuckoos nest, its obvious that Nurse Ratched played off of Billys fear of disappointing his mother and his depression as means of control.

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

8 It was the manipulation of power and the insensitivity of the shelters treatment methodology that drove me to the edge. Quite frankly, I couldnt take the impersonal method of care the shelter was providing. The agency simply wasnt helping enough of the clients long term and basic needs. So I left asking the question, is there a better way? According to Moxham, L. & Pegg, S.(2000), the manner society provides housing for the mentally ill is inadequate. The authors suggest that providing more community based environments will lead to deinstitutionalization in the men and women who suffer from mental illness and are in need of housing. Lastly, the authors highlight the importance of supportive and flexible housing alternatives, especially housing options which allow the residents more control over their options. While Moxam and Peggs article is an out of the box idea that directly challenges the current methodology agencies employ when housing indigent mentally ill patients, it meets the relational component needed to build trust between staff and client. According to Moxam et al (2000), clients who receive care in a community environment are more optimistic about their future, are more confident in the case management staff, more consistent with receiving and taking their needed medication, and most important, have a significantly lower rate of returning to the streetsall factors that institutionalized shelters have failed to actualize. Additionally, in a more recent study attempting to evaluate supportive housing, Nelson, Clarke, Febbraro & Hatzipantelis (2005) hear the stories of twenty homeless individuals who suffer from mental illness. The purpose of the study was to evaluate the effectiveness supportive housing had on the mentally ill homeless population. Using a qualitative approach, the researchers discovered that the quality of life before the individuals entered supportive housing was filled with anxiety and generally dark. In contrast, following the participants entrance into supportive housing, the participants reported a significant brighter perspective on life in general. The key term in the

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

9 aforementioned article is supportive housing. Shelters simply provide shelter while supportive housing agencies provide the one critical component shelters do notsupport.

After I left the shelter, I began working at a supportive community style housing agency. Our clients are in the same boat as the homeless men I served at the shelter and suffer from the same barriers (substance abuse, unemployment and mental illness). However, similar to the research cited above, the clients who live in the community style housing have more control over their own goals, more intimate contact with staff, are more open towards staff and subsequently have a better outlook on life. Most important, when a client completes and exits our program, they are more likely not to return to street living.

Discussion

Both in shelters and in mental health hospitals similar to One flew over the cuckoos nest a needed community service is provided. Tonights temperature is supposed to be in the low 20s. There are going to be nearly 600 people in the shelter protected from the elements. So at the least, 600 people wont freeze to death. Similarly, there are some mentally ill patients whose mental illness is so severe that institutionalization is the only answer. These chronically ill patients cannot function in society. To relegate them to the streets would put a large burden on both the community and themselves. Furthermore, there are some mental illnesses that are too severe for treatment in community style agencies. However, there is a large number of mentally ill homeless people who are in shelters and not receiving the basic needs they require regardless if there are resources or not. Thats not right.

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

10 In One flew over the cuckoos nest, McMurphy was an obviously rebellious and relationally challenged individual. The staff had ample opportunity to help McMurphy. However, the staff chose to abuse their power and take drastic measures to control McMurphy instead of recognizing that his needs come first, regardless of whether or not he wants the help. The staff at the hospital in the film violated one of the most important tenents of ethical health care managementthe care of the Other supersedes everything else.

Furthermore, having worked in an institutionalized agency, I have seen the staff put their own needs above their clients in both resources and relationship. The availability of resources is not the issue here (although thats what they tell the news). The shelter is more concerned with raising money and controlling their cliental instead of caring for them. In contrast, the supportive community housing agency I currently work for, emphasizes relationship and discourse as a necessary element to transitioning clients to a self-sufficient life of freedom.

Finally, has the health care ethical standpoint changed since and previously to 1975? While the treatment methods may have evolved, relational thrust has yet to be considered a necessity in long term care. So on one hand, technology and science have moved forward. However, the Health Care ethical standpoint of placing the needs of the Other over our own needs hasnt budged. Perhaps with additional research and funding for community based housing, serving the needs of the indigent mentally ill will transcend from the mid-20th century to todays ethical standard.

Quality or Care? A Close Look at Health Care Ethics Through the Lens of One flew over the cuckoo s nest

11 References

Arnett, R.C., Harden Fritz, J.M. & Bell, L.M. (2009) Communication Ethics Literacy. Thousand Oaks, CA: Sage Publications.

Moxham, L. & Pegg, S.(2000). Permanent and stable housing for individuals living with a mental illness in the community: A paradigm shift in attitude for mental health nurses. Australian & New Zealand Journal of Mental Health Nursing, 9(2), 82-88. doi:10.1046/j.1440-0979.2000.00162.x.

Nelson, G., Clarke, J., Febbraro, A., & Hatzipantelis, M. (2005). A narrative approach to the evaluation of supportive housing: Stories of homeless people who have experienced serious mental illness. Psychiatric Rehabilitation Journal, 29(2), 98-104. Retrieved from Academic Search Premier database.

Young, E. (2009). Memoirs: Rewriting the social construction of mental illness. Narrative Inquiry, 19(1), 52-68. doi:10.1075/ni.19.1.04you.

Zaentz, S. & Douglas, M. (Producers), & M. Forman (Director). (1975). One flew over the cuckoos nest. [Motion picture]. United States of America: Fantasy Films.