Balancing conflicts of obligation by design

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The most recognizable ethical principles associated with building design are those associated with greener, energy efficient buildings. It is hard not to support such clearly ethical aims, as they make financial sense as well. There are other ethical goals that building design can support, too, that are precisely aligned to the needs of specific client groups.

The design of London Centre of the Medical Foundation for the Care of Victims of Torture in the UK reflects the Foundation’s awareness of their clients’ experience of torture-related trauma.  The corridors are curved, unlike those in the detention centres and prisons where torture typically happens. Consulting rooms are larger than usual – avoiding the potential anxieties that come from feelings of confinement.  Decades of experience have informed this design aimed at minimizing the chances of inadvertent re-traumatization – doing good, while very consciously avoiding doing harm.

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For CAMH (the Centre for Addiction and Mental Health), similar considerations inform our ongoing redevelopment. With transforming lives as our vision, the transformation of our campus must serve that same end. The close attention to creating buildings that help provide transformative care meant that the first phase of our redevelopment won an International Academy for Design and Health Award.

Now in the throes of our third round of redevelopment, the same principles continue to inform the design. Recovery orientation, trauma informed care, community integration…all of these readily align with the ethics of care in mental health.

One principle, however, occupies a more complex place at the heart of planning our healing spaces.  The most central of all guiding principles at CAMH is safety.  Like many ethical principles, it can conflict directly with other important principles.  Safety most often comes at the cost of autonomy.  Or liberty. Or trust.  Or equity.  Safety is essential to care and to recovery, but the balance between safety and other essentials of a therapeutic space and a healthy workplace is often difficult to determine. Evidence may point in both directions; moral responsibilities certainly do.

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While a safe workplace is the primary concern, so, too, are the individual liberties of clients. Some clients have had those liberties justifiably restricted, but not all.  How do we preserve the liberty and autonomy of different clients while also ensuring the safety of all?  In a context that includes forensic services (where clients have become enmeshed in the legal system, often as a result of behaviours associated with their illness), the complexity increases.  Like all modern forensic psychiatric hospitals, CAMH must navigate the inherent conflicts of obligation between both providing the best therapeutic environment for people living with complex mental illnesses and assuring the safety and security of staff, clients and the public as well.

Equally, there is an ongoing challenge of avoiding the stigmatization of the people with whom we work. Building design can reinforce stigmatizing stereotypes and interactions.  In creating shared spaces, to be used as collective resources, how do we best address those competing duties?  Planning must factor all these duties together – protecting the vulnerable, preventing harm, ensuring safety for all, maximizing the therapeutic possibilities of the built environment and clearly justifying our allocation of resources.  In the final tally, limiting the liberties of some might need to be the lamentable cost of the safety of others.

Sometimes a little creative re-thinking and a few well-considered changes in conventional design can make a significant difference.  Technology can also assist with crafting spaces that engender calm rather than anxiety, ensure privacy, facilitate recovery and maximize autonomy while also safeguarding the welfare and security of all.  New technologies may emerge that help balance safety and restriction of freedoms.

When our planning of the new spaces for forensic services begins in earnest some years from now, balancing the competing obligations to both those who are working and those who are recovering in these environments will be a central concern.  Safety will be the central principle – evidence-based and ethically informed.