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Introduction

The Open University — Thu, 31 Mar 2011 08:45:04 GMT

This unit is from our archive and it is an adapted extract from Understanding Health and Social Care (K100) which is no longer in presentation. if you wish to study formally at The Open University, you may wish to explore the courses we offer in this curriculum area.

In this unit we explore questions of access to community services. To make what might be quite a dry task more challenging we use a fictionalised case study of two people for whom access to community services is particularly problematic. Jim and Marianne are both long-term heroin addicts. Additional problems associated with their addiction are homelessness and physical illness. Their situation raises both practical questions, about how services can be accessed, and moral questions, about entitlement to resources when their problems can be regarded as at least in part self-inflicted.

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Learning outcomes

The Open University — Thu, 31 Mar 2011 08:45:04 GMT

After studying this unit you should be able to:

appreciate key moral dilemmas about apportioning limited resources;
demonstrate an understanding of how heavy drug users test the limits of community services.

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1: Introducing Jim and Marianne

The Open University — Thu, 31 Mar 2011 08:45:04 GMT

The lifestyles of long-term drug abusers are frequently sensationalised

Long description

Jim and Marianne’s story is based on a real couple, but heavily fictionalised to protect their identity. Their story is a way of tracking the intricacies of the health and care system through the eyes of people for whom it is supposed to work.

Jim and Marianne, our case study for this unit, are ‘long-term heroin addicts’. The lifestyles of long-term drug abusers are frequently sensationalised in the media, as in the photograph, and the following extract fromTrainspotting, a novel about Scottish heroin users that was turned into a hugely successful film:

He droaps a cotton ball in tae the spoon n blaws oan it, before sucking up aboot 5 mls through the needle, intae the barrel ay the syringe. He's goat a f*****n’ huge blue vein tapped up which seems tae be almost comin through Ali's arm. He pierces the flesh and injects a wee bit slowly, before suckin blood back intae the chamber. Her lips are quivering as she gazes pleadingly at him for a second or two. Sick Boy's face looks ugly, leering and reptilian, before he slams the cocktail towards her brain.
She pulls back her heid, shuts her eyes and opens her mooth givin’ oot an orgasmic groan.
(Welsh, 1993, pp. 8–9)

However, I introduce Jim and Marianne not through a description of such gruesome practices, but through hearing about the people behind the heroin addict label.

Jim and Marianne

Jim and Marianne are a couple. When I met them for the first time they were in their early thirties. They had been together for about ten years. Although they had been having unprotected sex during these years they had no children and Marianne had never become pregnant. They met when they were both in a drug rehabilitation centre on the outskirts of a northern industrial town. They became the ‘star pupils’ of the centre.

They both tried to outdo each other in getting clean from drugs and in striving to become model citizens. They took up all sorts of sporting activities, participated in the groups and in the running of the centre. Eventually, the time to re-enter the community came and they were helped to move into their own flat. Jim was offered a job at the rehabilitation centre itself and Marianne, helped by her family, tried to establish a little business for herself buying and selling things from car boot sales and cheaper antique shops.

Jim described his childhood as ‘difficult’. He never knew his father, and he said his mother was unable to cope with him because of her own problems with alcohol. He had spent many of his childhood years in a variety of foster homes and children's homes.

Marianne's parents owned three newsagent shops and were comparatively prosperous. But, according to Marianne, the relationships within her family were not straightforward. Her father had a series of extra-marital affairs, but when his own health deteriorated he came back to be with his wife, Marianne's mother. Their relationship seemed to stabilise but Marianne said they had never been very communicative or demonstrative with each other, or with her, and usually tried to solve problems by spending money on them.

In Jim's words to Marianne:

I don't know what's better, my family who f****d me up when I was young, or yours who's always muckin’ us about now. They really do my head in. I know they don't like me, and blame me for things. They offer us things, but always with strings attached. I think they want you to leave me, and go back to them.

The quality of Jim and Marianne's lives deteriorated after a few years out of the rehabilitation centre. Neither of them could sustain the progress they had made. They found that making friends in the community who were not their old junkie’ friends was very difficult and they became quite socially isolated. Marianne described her family as supportive in some ways, but the emotional costs of getting help from them seemed to be considerable.

Jim felt patronised and Marianne felt unable to really confide in either of her parents and was wary of her brothers and their circles of friends. Together Jim and Marianne slipped back into increasing drug use. Jim lost his job immediately at the rehabilitation centre, which insisted on a drug-free environment, and Marianne found it harder than ever to make a living. Both confessed that they were involved in petty crime at this stage. Their general health started to decline.

Marianne found that the sites she was using for injection became persistently infected and she spent several spells in hospital with swollen legs and nasty ulcers. Jim had had a valve problem in his heart since birth. His lungs had been damaged by this and by the repeated chest infections he developed. Both of them had hepatitis C infection, which probably contributed to them feeling low in energy and being susceptible to persistent infections.

Activity 1: The people behind the label

The account in the case study box is about the people behind the drug addict label.

Did it change your view of them?
What advantages do you consider such additional knowledge might have for a health practitioner meeting Jim and Marianne for the first time?
Can you foresee any problems for a practitioner supplied with this additional information?

Discussion

Comment

People who read the course varied in their response. Two said emphatically that they did change their views. Another, accustomed to working with people who are often the subject of negative stereotyping, said: ‘I would always seek to find the person behind the label’.
Maybe a practitioner would have more sympathy with Jim and Marianne than if she had simply been presented with bald medical information – intravenous drug user, faulty heart valve, damaged lungs, infertility, subject to persistent low-level infection.

She might be less inclined to make moral judgements such as ‘they don't deserve help’ or ‘they brought it on themselves’.

The additional information might also suggest a broader range of helpful interventions than straightforward medical treatment: family therapy, even fertility treatment for Marianne, whose childlessness was a cause of regret.
A practitioner might feel overwhelmed by the plethora of problems. It would be much easier, perhaps, to prescribe some antibiotics, give some advice on diet or suggest a detoxification centre.

She might feel that even if she wanted to do more for them, resources were such that she should confine herself to her immediate remit, treatment for the problem as presented.

A doctor working in the biomedical framework may act differently from one who took a more holistic approach to patients’ problems. The next section takes this discussion further by looking at the moral dilemmas a real practitioner faces when coming into contact with people who clearly need help, but who may be classed as ‘difficult’.

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2: Moral dilemmas

The Open University — Thu, 31 Mar 2011 08:45:04 GMT

It is clear from the account of Jim and Marianne's lives that they need some help. But do they deserve help? Some of our course testers had very strong reactions to the inclusion of drug users in a course about health and social care. Here is one typical response:

I am not sure that Jim and Marianne and people like them deserve this sort of attention. Their problems were self-inflicted. It must have cost someone (we taxpayers?) a lot of money to rehabilitate them, yet they wasted the opportunity, cadged more money off Marianne's parents, stole from honest members of the community, and then expected to be bailed out by the NHS. Are there no limits to the obligations we all have to support people who seem determined to waste their lives, and damage the lives of others as they do so?

Do you share this attitude? It represents a clear challenge to the idea that everyone has rights to health and social care services simply because they happen to be resident in a community.

This question is one we could debate in abstract terms, but it takes a very concrete form when practitioners have to make decisions about resources, eligibility and priorities. Because I take a particular interest in drug users in my work as a GP, I have some experience of facing the issues. I explore some of them in the extract below, entitled Snowballs and Acorns: Medicine by impact (click on "view document").

Snowballs and Acorns: Medicine by Impact

View document

Activity 2: Tough decisions

Read the extract above. Concentrate on the dilemmas I faced in considering what to do when called out by Julia to examine her child. As this block is about communities, look at the question from two perspectives:

the GP's obligations to the individual
the GP's obligations to the community

and, under these headings, list the considerations involved in coming to a decision about taking Julia and her family on to the practice list.

Discussion

Comment

Obligations to the individual	Obligations to the community
Sick child, no fault of his own	Family will be expensive to treat, means fewer resources to spend on other (more deserving?) patients
Holistic view of Julia's situation suggests she needs help	Doctors should focus on things they can treat rather than trying to take on the troubles of the world
Julia is asking for help for the first time, responding to an empathetic doctor	Should not reward a deviant who has brought her troubles on her own head
May be an opportunity to stop this family sliding deeper into the mire	May be a constant drain on public money with no real return
No other agencies available to offer support	Democratically elected local authority has taken the decision to withdraw helping agencies; doctor should go with this consensus

In theory, everyone has the right to register with a GP practice, and expect treatment – something we examine in more detail below. There are other things to think about too.

It is not just Julia whose welfare is at stake: her children may be at some kind of risk. Any health or social care worker in contact with Julia's family will have to be aware of the Children Act 1989 principle that ‘the child's welfare is paramount’ (Department of Health, 1989a), and act accordingly. In the case of the GP this will mean checking with the health visitors attached to the practice, and asking them to visit. They will be obliged to take action if Julia is not providing the care that a ‘reasonable parent’ should supply under the circumstances.
In this sort of situation a GP may be professionally liable if things were to go wrong and the child became seriously ill as a result of negligence.
On this occasion my own needs, and those of my family, had to be put aside, but neither a GP nor any other health or social care worker can sustain this level of commitment to the welfare of others indefinitely.
In the Reader chapter I also reflect on why I am attracted to work with drug users. Is it solely out of altruism, or does this aspect of my work feed an unworthy personal need? And does that matter?

This chapter shows that just one small encounter can present a practitioner like me with a whole host of moral dilemmas. It is well nigh impossible to draw hard and fast rules when every case is different, and when personal as well as professional issues come into play. Legal requirements, such as the Children Act, mean that the question is not just a matter of individual judgement.

Moreover, such decisions have to be made not only at the face-to-face level, but in planning how to use limited resources.

Activity 3: Rationing resources

As a member of a health authority responsible for purchasing health services you are faced with a contracting budget. Given a choice between retaining an eight-bed drug rehabilitation centre (where someone like Julia could get treatment) and setting up four additional beds for acute psychiatric care, which would you choose?

Comment

This dilemma was faced by one health authority in 1997. The decision was to close the drug rehabilitation centre in favour of financing acute psychiatric care. Did you make the same choice?

If you did make the decision that Jim and Marianne, Julia and her children, are less deserving than people with acute psychiatric conditions, where would you draw the line? At treatment for motorists who drink or drive recklessly; cyclists who do not wear helmets; smokers; people who eat too much fatty food, or indulge in sports like ski-ing or horse riding, which carry a high risk of injury?

If you knew that a place in prison, where many drug users spend time, costs up to £30,000 a year, would that influence your decision?

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3: Testing the limits

The Open University — Thu, 31 Mar 2011 08:45:04 GMT

Choosing Jim and Marianne as the central case study in the unit was a deliberate strategy to enable you to consider conflicts at the very heart of health and social care:

the rights of the individual versus the rights of the community
the nature of community for people who have no settled abode
dilemmas about apportioning limited resources.

Following their story is a way of testing the limits of health and social care services, and exploring where community obligation should stop.

There are considerable moral and ethical issues involved in the debates around this case study. Do citizens have unlimited calls on health service resources, or are there limits to what services and facilities people could or should expect from the state? Do people whose problems may be considered to be ‘self-inflicted’ have the same rights and access to resources as other people? We will be reconsidering such questions at various points in the unit.

Key points

An approach that seeks to find the person behind the label is an antidote to their being seen simply as a collection of ‘problems’. It may also make a practitioner's task more complex.
Heavy drug users test the limits of community services.
Practitioners and planners are faced with moral dilemmas that are not susceptible to hard and fast rules.
When children are involved, the welfare of the adult patient or client is not the sole consideration.

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Next steps

The Open University — Thu, 31 Mar 2011 08:45:04 GMT

After completing this unit you may wish to study another OpenLearn Study Unit. Here are a few suggestions:

If you wish to study formally at The Open University, you may wish to explore the courses we offer in this curriculum area:

Health and Social Care

or find out about studying and developing your skills with The Open University

Or you might like to:

Post a message to theunit forum, to share your thoughts about the unit or talk to other OpenLearners

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References

The Open University — Thu, 31 Mar 2011 08:45:04 GMT

Department of Health (1989)An Introduction to the Children Act 1989, HMSO, London.

Welsh, I. (1993)Trainspotting, Minerva, London.

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Acknowledgements

The Open University — Thu, 31 Mar 2011 08:45:04 GMT

Except for third party materials and otherwise stated (see terms and conditions), this content is made available under a Creative Commons Attribution-NonCommercial-ShareAlike 2.0 Licence

Grateful acknowledgement is made to the following sources for permission to reproduce material in this Unit:

Illustrations

Christopher Jones

Unit Image

Sideshowmom: http://morguefile.com/archive/?display=76543

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