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Mental Capacity: Is choice the same as freedom?

Elderly man with head in his hands

If an adult in care can only select from a limited number of closed options, then do they really have what we might describe as ‘choice’?

Lucy Series argues that in many ways, we have come on a long way from the outmoded restrictive institutions of old. However, there are many new modern-age deprivations that have risen in their place. For example, many care homes will enforce a certain structure to the day in order to enable the cost-effective provision of meals, activities, and personal care support. In doing so, they are restricting natural choices and freedoms, while also enacting a system of close monitoring.

Gilded cages

This raises the question: are best interest decisions being made on behalf of the individual, or rather, are they being made based on what works best for the care home? Is choice the same as freedom?

In the case of P vs Cheshire West, Lady Hale famously stated that ‘a gilded cage is still a cage’. While we may seek to work in a person’s best interest, in doing so we place layers of restrictions upon them, depriving them of natural freedoms that they might follow were they not living in a care home. Whether this is having a bar of chocolate in the morning, showering during the day, or simply popping out to the shops whenever they wish.

Closed options as empowerment?

While closed options can often be restrictive, there is a case to say that limited options can potentially facilitate the active engagement of residents on any given day. Indeed, the choices on offer may even be designed to match the residents’ cognitive processing and communication. In this way, a closed option can potentially be a way to promote agency and not take it away.

However, we must always remember that closed choices are not the ideal option and should be used on a case by case basis. The options offered really should be based on the individual and their level of needs – which of course can change over time. We should always therefore recognise the limitations of closed choices, the remember that they need careful consideration, reflection and review.

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