The balance between autonomy and paternalism in mental health care: harm minimisation and self-injury

  • Patrick Sullivan

Student thesis: Phd


My thesis considers the philosophical and legal issues associated with the use of harm minimisation techniques in supporting people who self-injure. This approach is controversial as it allows the individual to continue to self-injure and is contrasted with approaches that attempt to prevent self-injury. It is argued that this tension is an illustration of the balance that has to be maintained between autonomy and paternalism that is played out on a daily basis in mental health in-patient units. The philosophical analysis has three main elements. First, I argue that harm minimisation can be supported on the basis that by continuing to allow harm, the health professional respects the individual’s autonomy and on balance, a net reduction in harm occurs. Second, I consider the objection that such an intervention represents a collusive relationship between the patient and the practitioner that supports a dysfunctional type of coping. This fails to deal with important underlying issues that are psychological in origin. This objection has both clinical and moral components. I argue on both clinical and ethical grounds that this argument fails. Third, I use the concept of epistemic injustice to develop an argument supporting harm minimisation based on the perspective of individuals with lived experience of self-injury. There are important moral reasons for recognising the validity of this perspective. Their narratives have challenged traditional ways of understanding self-injury. This has resulted in changes in clinical practice through the promotion of less restrictive forms of intervention. Harm minimisation is such an initiative and promotes individual autonomy. On the other hand, health care professionals must work in a specific policy and legal context. I argue that this context is dominated by concerns about liability and accountability, which is characterised by a preoccupation with risk and blame. I consider how this has an impact on the use of harm minimisation approaches, as the risk of serious harm or death in a patient subject to a harm minimisation programme although unlikely, cannot be excluded as a possibility. I accept that for many health care professionals and the organisations that employ them, this means that harm minimisation may be a less attractive option. This may result in the balance moving towards more paternalistic and more restrictive forms of intervention. In my conclusion, I reflect on these issues and conclude that harm minimisation is sometimes an option that provides an ethical alternative to more restrictive forms of intervention. Although it will not always be an option, it should undoubtedly be a consideration, and sometimes it provides an appropriate intervention. It validates the views and perspectives of some, although, not all individuals who self-injure. In doing this, it respects the reasons why they self-injure and their right to use coping strategies that work for them. However, for interventions such as harm minimisation to be used more widely changes in both perspective and practice are required.
Date of Award31 Dec 2019
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorSimona Giordano (Supervisor) & Nicola Glover-Thomas (Supervisor)


  • Mental health care
  • Harm minimisation
  • Autonomy
  • Paternalism
  • self-injury

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