Jayne Ruth Clapton

Autonomy and participation in rehabilitation: Time for a new paradigm?

The paper by Cardol et al brings together some important and complex considerations for rehabilitation in this century. These considerations involve the implementation of principles such as autonomy, participation, self-awareness, interdependence and an `ethic of care’ in the response to the need for client-centred practices in rehabilitation. This discussion re ̄ects upon the fact that these principles appear to be `odd bedfellows’, and highlights the need to further explore the conceptual and ethical implications they bring with them. Cardol et al. note that the concept of participation is fundamental to rehabilitation, but that it is often measured in terms of normative outcomes rather than the subjective wishes of the client. Accordingly, they suggest that the concept of autonomy is crucial to the successful operationalization of participation. Indeed, as stated by Cardol et al., autonomy may be a prerequisite for participation, and thus, the ultimate goal of rehabilitation. However, they note that the concept of autonomy is also subject to misinterpretation, presumably as a result of the predominance of the medical restorative model in rehabilitation. Together with many other researchers, they identify the fact that autonomy is often equated with either ®nancial or physical independence without acknowledging the signi®cance of interdependence in the daily life of all people. To address this problem, Cardol et al. argue for a distinction between decisional and executional autonomy, although the distinction is not always clear in their paper. This type of distinction is not new, albeit often overlooked and labelled in a variety of ways. For example, Stainton, de®nes autonomy as a `threshold concept’ that involves `the capacity of the individual to formulate and act on plans and purposes which are self-determined’. Furthermore, he discusses autonomous execution as consisting of the `conscious initiation and management of action’ which is both dispositionally (i.e. the ability to plan) and occurrently (i.e. concerned with actions and decisions) consistent with an individual’s valuation system. Therefore, irrespective of the labels given to the concepts, it is generally agreed that autonomy involves: (1) the ability to choose one’s activities or how they will be performed; and (2) the ability to actually perform that activity. As Cardol et al. observe, the degree of each type of autonomy will diVer depending on the activity and the context. They note how respect for clients’ `potential for autonomy’ on the part of rehabilitation providers, although vital at all times, is considerably threatened by the individualist liberal view of autonomy. Regrettably, however, they do not expand this claim by examining the ethical implications of this view for the rehabilitation context. It would have been useful to their discussion to have explored the implicit philosophical notions of competency, self-awareness, capability and capacity 6 with the resulting implications for individuals as rights bearers. Thus, although the merit of the ideas expressed by Cardol et al. is undeniable and the distinction they make between decisional and executional autonomy is a useful contribution to rehabilitation practice, conceptual problems emerge which, we believe, command discussion.

Time for a shift in Australian rehabilitation

Purpose. Tertiary rehabilitation, particularly in Australia, still costs a significant amount of money each year. Turnover in the rehabilitation industry is extremely high and rehabilitation professionals report being dissatisfied in their work. These ironic findings can be attributed to the state of tension in which rehabilitation finds itself. A decade ago, it was noted that tertiary rehabilitation counselling was facing the challenge of managing several conflicting forces and constantly shifting priorities. In the last decade, this challenge has intensified. Method. A review of current data was undertaken to identify the primary tensions that have influenced rehabilitation over the last decade. Results. Tensions were attributed to three sets of opposing forces related to the philosophy of rehabilitation, the economic imperative and the role of privatisation of the industry. Conclusion. This paper argues the need for a fundamental shift in thinking if the rehabilitation discipline is to continue growing. Precedents exist that can assist rehabilitation to make a significant shift to a new model of thinking, but a great deal of attention must be focused on the legal, economic and medical barriers to that movement.

Trends in Australian rehabilitation: Reviving its humanitarian core

Purpose. This paper discusses how vocational rehabilitation (VR) in Australia has been captured by economic concerns, leading to its failure to deliver promised outcomes. Both public and private sector VR in Australia have undergone significant changes over the last two decades. The demise of non-profit and socially-based rehabilitation in favour of fixed funding models (e.g., managed care or case-base funding), coupled with the growing emphasis on cost containment has placed many VR providers in an unfamiliar environment dominated by bureaucratic, legal, economic and political imperatives. Although it was expected that VR would address rising injury costs, its inability to do so has jeopardized its existence. Conclusion. Ironically, it is economic imperatives that are now prompting the re-invention of old concepts that appear to offer the same cost-containment possibilities rehabilitation offered in the 1990s. The most significant among these trends are self-management, coordinated care, community rehabilitation and welfare-to-work incentives. Perhaps the major challenge now, however, is to define a new dimension for rehabilitation and capture the essence of these trends to ensure that they contribute to a possible revival of a model of VR that focuses on the clients broad social context and responds to client-centred goals.

Towards an Understanding of Spirituality in the Context of Nonverbal Autism: A Scoping Review

ABSTRACT People with nonverbal autism are an underresearched group. Spirituality is fundamental to all humanness; therefore, the spirituality of these people is worthy of exploration. A scoping literature review involving comprehensive searches of empirical literature was conducted in three phases, with main themes identified. Gaps in academic literature prompted a further two search phases focused on nonacademic works. Little empirical research exists concerning the spirituality of people with nonverbal autism. Nonacademic literature provides a valuable source of information on this topic. This research forms part of a continuing study, so it is limited to identifying research gaps and future research directions.

Disability, Ethics and Biotechnology: Where are we now?

SUMMARY This paper was originally presented in memory of Jennifer Fitzgerald, as an address at a Queensland conference. Jennifer Fitzgerald was a lawyer and writer working in the 1990s with Queensland Advocacy Incorporated (QAI), an independent, community-based systems advocacy and legal advocacy organisation for people with disability in Queensland, Australia. As QAIs first bioethics advocacy worker, Jenny insightfully identified the threats posed by areas of biotechnology, for people with disability. Her works include a collection of papers on ethical issues facing people with disability, and “Include Me In: Disability Rights and the Law in Queensland” (1994). She was also a published participant of the first conference on Disability, Health and Spirituality held in Brisbane in 1996.