Postscript – on risk and making hard choices

Following on from my musings on Munby P’s rhetorical question – What good is it making someone safer if it merely makes them miserable? – Chris Hatton asked some sensible questions about how ‘risk’ itself is construed for people with learning disabilities.  He’s written a great blog post about risk and decision making capacity, which as a follower of Chris’ blog I’m embarrassed to have missed, so I’m making up for it by mentioning it here.  It’s well worth reading.

After I’d posted, I remembered a few other related things I’ve been meaning to mention anyway that you might find interesting.  The first is an episode of Inside the Ethics Committee (readers’ favourite radio program, surely?) featuring the wonderful Kaliya Franklin (aka @BendyGirl).  The program is about assisted contraception and disability.  But the part that really stood out to me was listening to Kaliya talking about risk, saying:

disabled people understand risk in a very different way from people who aren’t disabled and particularly from clinicians because we live with that risk as part of our everyday life, so we learn to accept that and deal with it.

This particular passage is given as a clip on the website, but the program is worth listening to in full.

Another point which it occurred to me that I should have made, is that intervening to protect people from risks doesn’t guarantee safety in any case.  That’s not to say we shouldn’t ever do it, but risk averse interventions carry serious risks themselves (if you don’t believe me, then read this report by CQC (you’ll find Connor’s story familiar).  The story of what happened to Lisa is one of the most shocking things I’ve read – I cannot fathom what the professionals – including presumably advocates and lawyers and judges involved in her detention – were thinking, and it is terrifying that it took CQC 9 years to notice this).

The last random association I’ll mention is a TED talk by Ruth Chang about how to make hard choices.  (I’m paraphrasing horribly because the last time I listened to this talk was a few weeks ago and I was digging up brambles at the time).  Chang talks about different kinds of choices – some are easy, because the available alternatives are contrasting things that are comparable to each other.  So if what we want is safety, then we can compare which of the available choices is the safest.  If we just want money, we take the highest paying job.  But ‘hard choices’ are choices where the available alternatives reflect different values.  We all face these types of hard choices – competing ideas for what kind of career we want (or whether we want one at all), balancing competing priorities of family and work, of fun and work, of fun and family.  And, in the the context of ‘safeguarding’, different alternatives might offer physical security whilst others might offer other things we value like familiar surroundings, living in one’s own home, living with family, having greater autonomy; choosing between these is a ‘hard choice’ on Chang’s view.

Chang’s argument is that we cannot ‘balance’ these contrasting choices because they are not comparable, we cannot ‘balance’ them at all because they are not of the same scale, of the same dimension.  I found Chang’s arguments quite plausible, but they present a real challenge to the pseudo-scientific account of the MCA ‘best interests balance sheet’. These factors cannot be balanced.  They cannot be totted up like a set of accounts, to select which is the ‘better’ outcome on a single set of criteria.  Which is not to say that it’s not helpful to consider the pros and cons of different alternatives, but there is no scientific balancing exercise here, there are simply hard choices.  Chang goes on to say that in these contexts what we are doing is not ‘balancing’ alternatives, but exercising agency, constructing our ‘self’, it is a process of identity formation, not a logical or scientific process.  The problem of course in the context of ‘best interests’ decisions (if you haven’t spotted this already) is that Chang’s approach to hard choices rests on the person themselves making the choice, not others making it for them.  They are about something more like authenticity than they are about rationality.  The CRPD approach of maximising accord with a person’s will and preferences in some ways is closer to Chang’s view, but even this is tricky as outsiders may construct a person’s ‘will and preferences’ in very different ways (a topic for another day).  So hard choices are hard, but hard choices made on behalf of others (even if they are striving to maximise accordance with a person’s own ‘narrative’ or preferences) are really, really hard.

Anyway, I don’t have any answers (as usual), but I thought I’d share these bits and bobs with you as I found them interesting and you might too.  Have a great weekend!

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2 thoughts on “Postscript – on risk and making hard choices

    • Thanks Tor, I’ll add that to my Christmas list!

      Have you come across the work of Nev Jones? I’m telling everyone about her at the moment as I think she’s one of the most interesting and important researchers in mental health at the moment. She is very involved in the hearing voices movement, and she has experiences of psychosis and hearing voices herself. Loads of her papers are on academia.edu:
      https://stanford.academia.edu/NevJones

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