The Shift of Responsibility in Care Processes during the Last Decades
Abstract
This article – in the form of a retrospective reflection – refers to changes in the allocation of responsibility in psychiatric care processes as witnessed by the author since the 1960s. The empirical background is taken primarily from inpatient institutions in Vienna, but probably also reflects situations more generally. The one-sided allocation of responsibility to (mostly iatric) professionals – and their correlating claim to this responsibility – has been superseded by a multilateral allocation of responsibility in care processes. Of course, professionals still play an important role (and the procedure of decision-making has become more complex because healthcare professionals other than doctors – nurses, psychologists, psychotherapists, social workers, etc. – claimed to their own responsibility). However, the patients concerned have progressively gained significance. While social entities always were and remain responsible for the underlying conditions of care processes, their responsibilities have meanwhile become significantly more pronounced. These changes result in a need for orientation, which can be satisfied by sketching a triangular ‘topography of responsibility’.Psychiatric care processes, responsibility, autonomy, topography of responsibility, ethics, history of psychiatry
With the aid of three anecdotes and their brief analysis, I would like to clarify, in this short article, the traditional establishment of responsibility in psychiatric care processes.
I experienced the first anecdote myself, after having been appointed, in 1978, Medical Director of what was then the psychiatric hospital of the city of Vienna, Baumgartner Höhe. While observing the patient groups occupied in professional ergotherapy, I had the opportunity to visit the group employed in the institution’s orchard. There I met physically healthy patients who were so sensible in their behaviour that they could be occupied within an open group. However, they were not allowed to use stepladders to pick the pears, but instead had to beat the fruits off the trees with sticks. The pears were particularly fine and naturally got damaged in the process. The explanation given for this restriction was the potential risk of patients falling off the ladders. This risk was probably the same as it would have been for any other healthy and sensible person using a ladder for their work. The patients, however, were deemed incapable of appropriately judging their individual risk and of taking the responsibility for their own actions, because they were in residential treatment for a mental illness at a hospital and because their good present condition was not taken into account appropriately.
This type of formalistic assessment had a long-standing tradition, which brings me to add the second anecdote. The old administration files of the institution contain documentation about a visit by an American delegation to the ‘Irrenanstalt [mental asylum] Am Steinhof’ (as it was originally called), hailed as a very modern institution, soon after its opening in 1907. This delegation visited the institution in a motorcade. Because of the dangers of automobile traffic, the director took the precaution of forbidding patients to leave the hospital buildings during the visit. He did this because, as director, he felt totally responsible and did not recognise the patients’ own personal responsibility.2
- Schlöss H, [The organisation of the medical service in the Lower Austria provincial health and nursing institutions for mental and nervous diseases Am Steinhof], Psychiatrisch-neurologische Wochenschrift, 1907; special issue:27–33.
- Gabriel E, 100 Jahre Gesundheitsstandort Baumgartner Höhe. Von den Heil- und Pflegeanstalten Am Steinhof zum Otto-Wagner-Spital, Vienna: Facultas, 2007.
- Gabriel E, [Experiences with Tofranil in the psychiatric consultation], Wien Med Wochenschr, 1962;112:222–7.
- Hofmann G, [Remarks on the work of Ernst Gabriel ‘Experiences with Tofranil in the psychiatric consultation’], Wien Med Wochenschr, 1962;112:476–7.
- Gabriel E, [Concluding words on the preceding remarks from Gustav Hofmann], Wien Med Wochenschr, 1962;112:477.
- Forster R, Pelikan JM, Patientenversorgung und Personalhandeln im Kontext einer Psychiatrischen Sonderanstalt. Eine Organisationssoziologische Untersuchung im Psychiatrischen Krankenhaus der Gemeinde Wien “Baumgartner Höhe”, Vienna: Institut für Höhere Studien, 1978.
- Fengler C, Fengler T, Alltag in der Anstalt, Rehburg-Loccum: Psychiatrie-Verlag, 1980.
- Jonas H, Das Prinzip Verantwortung, Frankfurt am Main: Insel Verlag, 1979.
- Strotzka H, Fairness, Verantwortung, Fantasie. Eine psychoanalytische Alltagsethik, Vienna: Deuticke, 1983.
