the use of compulsion that requires a justification. There are two reasons for this:
that individual autonomy is a value to be preserved whenever possible, unless it
thwarts other important values #some would say, even then), and that people are
normally the best judges of their own interests, even if they are not perfect judges.
Both in technical philosophy and in practical life there is a dispute as to whether
both reasons are valid, and if only one, which one, and also as to exactly how
strong our commitment to autonomy should be. But that our presumption should
be in favour of autonomy is widely, and I think rightly, agreed.
There are also two main grounds for overriding individual autonomy, but here it
is the two in combination rather than as alternatives that are needed. The patient
or client must be unable to make a rational decision about treatment, and they
must be likely to injure themselves or others if nothing is done. We shall consider
later whether one of these could be ethically sufficient, but for the moment we may
take it that when both are believed to be present compulsion is regarded as
necessary, whether in the form of compulsory hospitalisation, compulsory medi-
cation or other treatment, or compulsory seclusion or restraint.
Some of these decisions, especially the decision to detain a person in hospital,
will be taken by people other than nurses. Chapter 9A explains very carefully and
clearly the legal position of the nurse once this has happened. This may involve
only making sure that the proposed treatment is lawful under the Mental Health
Act, or it may involve decisions as to whether the patient is competent and whether
they are dangerous to themselves or others. It is in these cases that there is an
obligation on the nurse to carry out the law ethically.
To carry out the law ethically means, in this context as in many others, to take its
provisions seriously, and not to take action for other reasons or on other criteria.
The question whether a patient is competent ± which can be a very difficult one ±
must be decided with regard to the individual patient, and not on the basis that a
certain type of person, or a person with a certain type of disorder, or a person
making a certain sort of decision, is necessarily incompetent; Chapter 9A points
out that the law intends all this to be excluded. Similarly, the judgement whether
seclusion is necessary needs to be made with regard to the individual, without a
presumption that all members of some particular group are inclined towards
violence.
Secondly, as well as being imposed on the right criteria, restraint and compul-
sory treatment must always be imposed for the right reasons. The main wrong reason' is as a punishment, but it is very important for nurses to remember that one can be punitive informally and even unconsciously. The best policy may be for nurses to acknowledge their #often justified) anger with certain patients and then to exercise professional self-control, rather than failing to admit the hostility, which may then influence their actions while remaining unnoticed. The otherwrong reason' is administrative convenience. To use seclusion when
apatient is likely to be violent or seriously disruptive is obviously right and
necessary; but, despite the temptation, to use it when they are only a nuisance is
not. There are practical worries regarding this, that in some hospitals the use of
seclusion is too frequent and the correct legal guidelines are not only not properly
followed but also not properly explained during training. The result is that a
culture of the use of seclusion #or of other forms of restraint or compulsory
186 NursingLawandEthics