Isolation can cause harm in everyday life. Some people choose to be isolated and are pejoratively labelled hermits or recluses. Others may choose to live an isolated life because they prefer privacy to social groups.
It was recently reported across the media that close to 12 000 young adults have maladies caused by isolation during the COVID-19 pandemic. That is what the recorded figures show, and there may be many more. However, it is not only pandemics which cause isolation and their attendant adverse consequences. The COVID-19 pandemic led to widespread isolation not just of people whose natural tendency was to be alone but also many others whose natural tendency would be outgoing and gregarious.
Isolation can have adverse effects in the community setting, as patients are usually bound to their homes. Taking on responsibility for a patient in the community who is isolated can entail a responsibility to steer them on a course, which they might otherwise not have taken and which might redound to their benefit.
Isolation in popular culture
The image of personal isolation is more often than not, a negative image. Being alone is somehow thought of as a minus, contrasted with being in a group, which is a plus. To follow this assumption could cause great harm. Some people are clinically agoraphobic (which does not, despite its etymology, imply an aversion to market places though it could include them) and manage to get through life quite well. Some other people are only happy when they are in a crowd. Others are said to be ‘good company’ or even ‘the life and soul of the party’. Some are just a pain in the neck.
The emergence of clinics devoted to weaning people off internet addiction has been noteworthy in Japan but is taking hold in the West (treatment in clinics, that is, as well as the addiction). Internet use can have positive effects and users who subscribe to certain sites are referred (by the purveyors) as ‘communities’. I do not regard myself as a member of such a ‘community’, partly because no such community exists and partly because a lot of it is factually wrong. No community nurse (CN) in their right senses would encourage a housebound patient to glue themselves to a screen.
Isolation as a malady
So far, we have looked at isolation as a negative rather than as a positive state—that clinically harmful consequences can follow isolation and must be a common experience of CNs. The legal responsibility of the CN is to do for their patients what is generally regarded as proper for the individual patient, and there is no one-size-fits-all for every case. It is, rather, to the ethical implications of the professional choice between intervention and the considered choice not to intervene, that we should turn if any useful guidance is to be given. In entering this ethical arena, a whole host of values and principles present themselves for consideration. Above all values, the value of privacy is to be observed and implemented if patient individuality is to be protected.
As a general rule there is no tort (civil wrong actionable in damages) of breach of privacy. Such breaches of privacy as are the subject of a lawsuit are in fact by-products of more specific breaches of the law such as ‘phone hacking and associated breaches of wireless and telecommunications legislation. Were there to be an actionable legal wrong as breach of privacy as such, then people would be able to sue anyone else for pretty anything.
CNs may meet patients who value their privacy for reasons which may be identified as clinical. These include paranoia, obsessive compulsive disorder (doing things in a private, overly systematic or number-directed way) or simply, acute shyness. So long as the behaviour occasioned by these conditions causes no harm to others then there are some who might counsel doing nothing. But CNs whose professional experience indicates harm to the patient's mental welfare and, by consequence, to the welfare of others looking after them, have at least an ethical duty and possible legal duty to weigh the consequences of non-intervention with those of doing something or suggesting to carers, some positive course of action. This choice will ring bells with many readers. I have heard it said that checking ten times that you have your door key is preferable to locking yourself out, that is, provided you don't have to check it so much that you never get out in the first place.
Isolation on account of limited ability
During the COVID-19 pandemic the media was replete with reports of people being ‘isolated’ in care homes without a way out. The restraint on personal liberty may have been for good reasons and the sense of responsibility of right-thinking care home staff. Or it might have been for less acceptable, and less lawful reasons, including the self-righteousness of some care home managers. To some such managers the concepts of judgement and discretion seem to have been altogether alien. Take the case, for instance, of the GP whose mother resided in a care home at the height of the pandemic when homes were deliberately denied access to preventive clothing and equipment, it being routed to the NHS. She became concerned that the inadequate protective measures in the care home could expose her mother to COVID-19 so she decided that her mother should live with her instead.
However, the home's managers and someone called the police. In the face of the enormous scarcity of police resources (given as the reason for up to 95% of crimes remaining unsolved) the police arrested the GP. The alleged offence committed by the GP was never reported nor was it vouchsafed to the media by the ‘attending officers’ or their bosses. Perhaps because no offence was committed. Nonetheless, their senior officer was reported to have described their conduct as ‘overzealous’.
The lady in question was later (very soon, actually) announced proudly by the same senior officer to have been ‘de-arrested’. It is ample demonstration of the depths to which civil liberties in the UK have sunk. No wonder some people choose to stay inside with their locked doors. It may be a bit limiting, but at least you avoid arrest.
Isolation in mental health care
If a person has been ‘sectioned’ under the Mental Health Acts, whether or not they have committed a crime, lawful physical restraint my be used in their care and treatment, provided that such restraint is proportionate to the circumstances of a given situation. The use of straitjackets and Buxton chairs is still practised unlawfully in response, often though by no means always, on account of staff shortages. Those caring for vulnerable patients who might foreseeably wander off and come to harm may be faced with the unenviable quandary of breaking the law by restraint and letting a patient come to harm. The legal implications of this quandary are considerable but are beyond the scope of this article. They will not be beyond it when a case comes to court.
One aspect of restraint and freedom in mental health care is, however, beyond doubt. There is a dangerous myth that it is unlawful to keep informal (not detained under mental health legislation) patients in a locked ward. It could be unlawful, but it is not necessarily so. Take the case of an informal patient who does not have the mental capacity or the wits to stay in the safe confines of the ward unless reliable accompaniment is at hand and free to guide them. The door to the ward may perfectly and lawfully be kept locked. It is as simple as that.
There are still colleges up and down the land who tell their students that it is always unlawful. I witnessed the dissemination of this when I was a member of the Mental Health Act Commission for England and Wales during the 1980s for 8 years. For all I know, this disinformation is still being churned out. Once a myth like this gets into the woodwork, it is very difficult to get it out. I was even told by a GP member of an appointments committee charged with the selection of a Patients' Rights Officer for their hospital that I was wrong and that they had been given the information ‘by the Commission’. How much of the Commission's misconceived detritus is still lying around I shudder to think.