Deema al Yousuf
Kathryn Cobain
Shagun Misra
David Jeffrey
Worcester, United Kingdom

Background

The UK’s Mental Capacity Act (2005) stresses the importance of patient involvement in the process of informed consent through shared decision-making.¹ A workshop was held for forty-one first-year graduate medical students to raise their awareness of this Act. To stimulate their interest, an extract of Clive Donner’s 1963 film The Caretaker was used to provoke reflection and discussion.^2,3

The film is based upon the play of the same name by Harold Pinter and depicts a power struggle between an elderly, homeless man named Davies and two brothers , Aston and Mick.⁴ It opens with Aston kindly offering Davies a bed, although the dilapidated house appears to belong to his brother. Aston is quiet and withdrawn, spending much of the play fiddling with an electric plug and talking about his goal to build a shed in the garden. During the play, Davies listens while he describes an experience of electric shock treatment (ECT), which had been administered against his will.^2,3

The students watched a ten-minute clip of Aston’s monologue which provoked lively discussion and generated the following reflections and questions from the students:

Was Aston mentally ill?

It was unclear from the short video Aston’s age and situation before his detainment, or whether he had received any treatment before receiving ECT. It seems that Pinter deliberately left us in the dark about these circumstances to provoke thoughts about the situation. This is comparable to the uncertain situation facing doctors in clinical practice where information about the patient may be incomplete.

It was difficult for the students to decide whether Aston was mentally unwell when he had received ECT. From Aston’s own account, it seems that he had minimal communication and exhibited obsessive behaviour and paranoid thoughts, which could be consistent with schizophrenia. On the other hand, Aston may not have been mentally unwell but merely perceived so because he was different from his peers. The story also highlights how general practice in the UK has changed, as previously patients would see the same family doctor over time. Nowadays, patients tend to see different doctors who may not be familiar with their psychosocial history. This emphasised the importance of continuity in patient care, particularly for those with mental health problems.

Did Aston give valid consent?

The students agreed that Aston did not consent to his ECT. Instead, a paternalistic doctor left him out of the decision-making process. The students felt he should have been given the opportunity to reflect on his choices and give or refuse consent to the treatment.

What barriers did Aston face to giving informed consent?

The students felt that Aston was coerced into undergoing a treatment that he did not understand. He was not provided with information and was not involved in the treatment plan. He was told he was going to undergo ECT but was not given time for deliberation or allowed to ask relevant questions.

The students reflected that in current practice informed consent is a process rather than an event. During this process the patient is given time to consider honest information and to weigh up risks and benefits of any proposed treatment. They suggested that the doctor should check that the information provided had been understood by the patient.

Students commented that the lack of consent displayed in the clip allowed them to reflect on the importance of autonomy and information sharing in patient care. Students had a strong sense of compassion towards Aston as he spoke about feeling completely left out of control of his treatment. The clip encouraged the students to explore how medicine should be a sharing of power between doctor and patient, where both are equally involved in making the decisions.

​Did Aston have capacity?

The video highlighted the difficulty of assessing a patient’s capacity, sparking a variety of opinions, generating a sense of uncertainty among the participants. Aston talked about his odd conversations in a café, and his fidgeting and ruminating were certainly obsessive. The students appreciated that assessing capacity was not always straightforward but felt that the doctors’ approach should have been different. They would have started by assuming the patient had capacity. If in doubt, they should have taken practical steps to aid decision-making, remembering that patients are allowed to make unwise decisions​. Finally, if they did decide that the patient lacked capacity, they should use the least restrictive alternatives.

How could Aston’s capacity have been enhanced?

The students discussed ways in which Aston’s capacity could have been enhanced: providing him with information regarding the benefits and risks of treatment, speaking to him at a time when he might understand the information, and checking his medication. Some felt he should have been given more time to weigh-up the decision; others suggested that Aston could have had medication before resorting to ECT therapy to assess whether his capacity could improve.

The doctor may have also utilized visual aids and clear language—the medical jargon and complex language used hindered Aston’s ability to consent or understand the proposed treatment. The absence of a multidisciplinary assessment, perhaps involving psychologists, social workers, and other healthcare professionals, suggests a need for a more comprehensive and impartial evaluation of Aston’s capacity.

Did Aston need to be confined?

From the evidence of his monologue, the students did not feel that Aston posed a danger to himself or to others. There is no mention of Aston having any assessment before his compulsory admission. Instead, Aston said he was threatened with long term confinement if he did not have the ECT. There is also no talk of Aston receiving any follow up after his ECT. Compulsory detention should be justified for a patient only for their health and safety or that of others. The students debated whether in fact a Mental Health Act is necessary.

Evaluation: Reflective accounts

The two students co-facilitating the session found the workshop was challenging and enlightening. Approaching a workshop centered on uncertainty initially made them feel a sense of apprehension. The interactive nature of the session was seen as a valuable tool for facilitating group expression and understanding.

To one participant, the discussion showed that the complexity of capacity was not something we had explored much in the past. The interactive session helped make the topic a more appealing and engaging one.The video also served as a powerful narrative device, underlining the timeless relevance of Pinter’s work. The content of the video emphasised the gravity of the subject and helped personify the dilemma, proving to be far more captivating than simply reading cases. Using a vintage film clip enabled students to reflect on a more appropriate, shared model of decision—making patients more involved in decisions about their treatment.

References

1. NHS. Mental Capacity Act 2005 [26th March 2024]. Available from: https://www.nhs.uk/conditions/social-care-and-support-guide/making-decisions-for-someone-else/mental-capacity-act/.
2. Jeffrey E, Jeffrey D. Enhancing empathy: a drama workshop. Education for Primary Care. 2016. doi: 10.1080/14739879.2015.1119980
3. Pinter H. The Caretaker 1963 [26th March 2024]. Available from: https://www.youtube.com/watch?v=kRi7AVCAKKc.
4. Jeffrey E, Jeffrey D. Enhancing Compassion in End-of-Life Care Through Drama: The Silent Treatment. London: Radcliffe Publishing; 2013.

Acknowledgement

The authors would like to thank the first-year medical students of the Three Counties Medical School, University of Worcester, UK, who participated in the workshop.