Analysing the Concept of Informed Consent in Healthcare

Analysing the Concept of Informed Consent in Healthcare Chapter 1-Introduction 1.1 In modern society, everyone has the basic right to consent to medical treatment. However, this is a recent development as consent was not always considered a critical issue in medical treatment. Hippocrates himself, advised doctors that they should conceal the effects of medical treatment from their patients, his reasoning being he believed that when patients were given relevant information they would take a turn for the worse. It was not standard practice for patients to question a doctors decision or authority. Recent changes have contributed to this change in attitude and as such altered the method of practice of a doctors obligation. The final years of the twentieth century as witnessed the most dramatic shift in the reputation of the medical profession within the United Kingdom, due to scandal after scandal plaguing doctors. Major news headlines left the doctor-patient relationship in a state of concern, for example, Doctors who steal organs face jail.This headline refers to the Bristol and Liverpool Hospital where it was discovered that they were retaining childrens organs, without consent or knowledge of the parents. It became apparent in the Bristol and Liverpool reports that organ retention, of both children and adults was widespread practice. Another significant humiliation for the medical profession was the case of Harold Shipman, a general practitioner who was convicted of murdering fifteen of his patients. Whether these circumstances are due to the actions of individualist or media influence makes little difference to the effect they had on societys viewpoint. There was need for change and this brought about the introduction of regulations and guidelines that protected both the patient and the doctor. 1.2 Informed consent was seen to break the doctor knows best concept and established a liberated choice for the patient. The locus classicus for informed consent is contained within the case Schloendroff v Society of New York Hospital, where it was held, â€Å"Every person being of adult years and sound mind has a right to determine what shall be done with his own body.† There are many examples within the UK system which confirms this principle of law, one being the case Re A (Minors) in which Robert Walker L.J stated, â€Å"Every human beings right to life carries with it, as an intrinsic part of it, rights of bodily integrity and autonomy The principle underpins the common law concerning consent to treatment within the UK. The consent that a patient has the right to choose is a fundamental part of receiving medical treatment. No considerations need to be examined whether the choice is rational or irrational, as the patient has an absolute right. 1.3 The Department of Health 1993 stated, â€Å"Consent is the voluntary and continuing permission of the patient to receive a particular treatment based on an adequate knowledge of the purpose, nature and likely risks of the treatment including the likelihood of its success and any alternatives to it.† Meaning any permission given under any unfair or undue pressure is not consent. Consent may be expressed or implied, however the validity of informed consent does not depend upon the form in which it is given 1.4 This dissertation will firstly consider the development of informed consent, as the English courts initially had reservations of its establishment and for this reason was gradually introduced in stages, until the case of Chester v Afshar which saw the full acceptance of the doctrine. It needs to be considered how the medical profession dealt with this change and in addition how patients themselves are exercising such powers. The effect in which the Human Acts 1998 has had on the courts decision making process will also be analysed to observe the relevance this may have had on informed consent. Another factor of informed consent includes giving sufficient information and the patients understanding of this. For informed consent to exist, the patient must have all the relevant information and capability to make an informed choice as to the treatment they decide to receive. This was made apparent in the case Reibiu v Hughes, where Laskin J stated, â€Å"the genuineness of consent to medical treatment depends on proper disclosure of the risks it entails† For informed consent to exist within the UK; provisions need to be made for those who are simply unable to give an informed choice. The capacity of a patient needs to be considered and if they lack this then a doctor must make a decision as to what is in the patients best interest. This can be seen to restrict informed consent as it goes against its true principle, however if a patient can not make an informed choice for themselves then it is only passable that someone has to act on their behalf. This dissertation will examine the procedure for this and how the law enables decisions to be made fairly and respectably. Chapter 2-The Development of Informed Consent 2.1 The area of law that needs to be established is the nature and scope of the duty to inform and the extent to which this has been incorporated into the English legal system. The existence of a duty to warn came about when the relationship between a doctor and the patient, which was based solely on trust, began to erode. There was a need for scrutiny and examination within the medical profession and this was achieved through the development of the law. The scope of the doctors duty of care is determined by a reference to the Bolam case. Mr Bolam agreed to electroconvulsive therapy to help improve his depression. He suffered fractures in the course of the treatment. The risk was known to his doctor, but he had not informed Mr Bolam of such. Mr Bolam alleged that the failure to warn him of the risk was negligent. The judge found that the amount of information harmonized with accepted medical practice and dismissed his claim. The judge, McNair J, directed the jury to the principle that, â€Å"A doctor is not guilty of negligence if he has acted in accordance with the practice accepted as proper by a responsible body of medical men skilled in that particular art† Therefore, the defendant doctor had conformed with a practice which was approved by a responsible body of medical opinion. This test was known as the Bolam test and it determines whether the doctor fell below â€Å"the standard of the ordinary skilled man exercising and professing to have that special skill† 2.2 Where there is a difference of judgment between two differing medical opinions, the defendant will be given the benefit of the doubt. As a result a doctor would not be found negligent if the court is satisfied that there is a responsible body of medical opinion that considers the doctor had acted appropriately. This responsible body need not be the majority of the profession. It appears that the courts allowed the medical profession to set their own standard. A doctor simply needed to provide an expert testimony and the courts assumed that it must be responsible. In exceptional cases, the courts perceived some established practice to be substandard, however it appears that only one reported case has materialized where such a judgement has occurred. The case, Hucks v Cole, where a woman contracted puerperal fever due to her doctor failing to treat her with penicillin for her septic toe and finger. Although a number of distinguished doctors gave evidence that they would not have administrated penicillin, the Court of Appeal found the defendant to have been negligent. The Judge, Sachs LJ, commented that the courts have to be in a position to verify that the medical opinion stood up to logical analysis and that they are not merely tailored to fit the requirements of the respective parties cases. This judgement was one of rarity, as Judges would not ordinarily cross examine a doctors opinion on a logical basis. 2.3 Often cases were even more favourable to the doctor, as is witnessed in the case Hatcher v Black. In this case Lord Denning stated, â€Å"As a matter of law it might be justifiable for a doctor to tell a lie, when he only does that which many a wise and good doctor would do.† It can be concluded from this that it is entirely for the individual doctor to determine what to inform his patient, even if the doctor went so far as to opt for what his lordship termed a therapeutic lie. Professor Michael Jones expressed the state of play as a football score, â€Å"In six medical negligence claims before the House of Lords between 1980-1999 the score stood at Plaintiffs 0, Defendants 6†. 2.4 The Bolam test which was adopted by English law focused on accepted practice and responsible profession opinion. The story was very different in America, as the American Courts rejected the professional medical standard and instead emphasised the patients right to know what the risks are inherent in the treatment. In Canterbury v. Spence a US Court stated that the prudent patient should prevail and its the doctors duty to disclose to their patient any material risk in a proposed line of treatment. The prudent patient principle emphasises what the doctor needs to inform the patient, according to what the average reasonable patient would want to know about potential risks and treatment options. This is made evident when the Judge commented, â€Å"A risk is material when a reasonable person†¦.is likely to attach significance to the risk† Contrary to the English Courts, the USA placed more importance on the patients rights and exigencies than those of the doctors. However, soon after the Bolam decision the English law was making changes towards incorporating this American style of law, to incorporating the doctrine of informed consent. 2.5 The question that needs to be examined is to what extent the Bolam test does or should apply to the duty to inform. Sidaway v Board of Governors of the Bethlem Royal Hospital was the subsequent, leading case to appear before the House of Lords that approached such a matter. While the majority of Lordships legitimatised the traditional test expressed in the case of Mr Bolam, the individual judgements were small steps towards informed consent. Four out of the five Law Lords rejected the transatlantic test that a duty to inform a patient should be based on the reasonable or prudent patient and Lord Scarman alone favoured this manner of law. 2.6 Lord Scarman made it apparent that he considered the patient to have the right to choose what happens to his body, which signified the patient needs to know the risks so can exercise an informed choice. He went on to express what he held to be the suitable relationship between a doctor and his patient, â€Å"There is room in our law for a legal duty to warn a patient of the risk inherent in the treatment proposed†. He went on to consider the doctrine of informed consent and its relevance in the Canterbury case, â€Å"I think the Canterbury propositions reflect a legal truth which too much judicial reliance on medical judgment tends to obscure† Lord Scarman acknowledged the patients rights and that the prudent patient principle made the doctors much more accountable for their actions. As such he rejected the current medical practice that a patient will be informed if he needs to be, as opposed to if he wants to be. Doctors, in Lord Scarmans view, should be liable where the risk is such that in the courts view a prudent person in the patients situation would have regarded it significant. He appears to suggest that the onus proof rests on the doctor to satisfy the court as to the reasonableness of any non-disclosure and therefore suggesting a support for informed consent. However, it must be noted that he did not find in favour of Miss Sidaway, on the basis that she failed to establish that the less than one per cent risk was such that a reasonable patient would consider significant. 2.7 In spite of this the speech of Lord Scarman has stood as a symbol of hope to those who argue for informed consent to be introduced into English law. Lord Diplock rejects Lord Scarmans scrutiny, as he maintains that the Bolam test covers all aspects of the doctors duty to care to his patient. However, he distinguished from the position where a patient asks a question about treatment, by stating â€Å"if the patient in fact manifested this attitude by means of questions the doctor would tell him whatever it was the patient wanted to know.† This illustrates that while Lord Diplock believed doctors were not be required to inform the patient of risks, he does not fully discount the patients rights. Lord Bridge also rejected the notion that a patient should be warned of all risks, yet â€Å"when questioned specially by a patient of apparently sound mind about risks involved in a particular treatment proposed, the doctors duty must, in my opinion, be to answer both truthfully and as fully as the question requires.† This gives the patient the option of asking for information from the doctor and if the doctor failed to do so then his duty of care could be in breach. However, Lord Templeman, expressed that this is not clear cut, as â€Å"the court will be slow to conclude that the doctor has been guilty of a breach of duty owed to the patient merely because the doctor omits some specific item of information.† It was important that Lord Scarman recognised the doctrine of informed consent and that the remaining four judges recognised the meaning of a patients ability to enquire and the doctor responsibility to notify. 2.8 It seemed that English legal system was initially hesitant to adopt informed consent into medical law. However, the approach taken in the case Gold v Haringey Health Authority contradicts that expressed by their Lordships in Sidaway. The claimant, in this case, indicated that she did not wish to have any more children and was advised to undergo a sterilisation operation after the birth of her third child. The operation was carried out but the claimant later became pregnant and gave birth to her fourth child. The Judge at first instances applied his own analysis as to what information the doctor should have given and found the defendant negligent. Upon appeal, Lloyd L.J held that the Bolam test should be strictly applied and he dismissed the view of the judge prior to him. He asserted that for the purposes of establishing the test as to the duty of care owed by a doctor to a patient no distinction needed to be made between advice given in a therapeutic and non-therapeutic context. In reference to Sidaway he stated, â€Å"the House of Lords could have adopted the doctrine of informed consent favoured in United States of America and Canada, but the House of Lords decided not to follow that path.† It seems clear from the Sidaway judgement that the nature to inform is more extensive than that of the Bolam test where no information is required. The decision in Gold repealed any progress been made towards informed consent and the judgement seemed to convey patient autonomy to be rather trivial 2.9 The view of Diplock in Sidaway has been regarded as the authoritative statement regarding the extent of the doctors duty. There has been a move away from the Diplock approach as seen in the case Pearce v. United Bristol Health Care NHS Trust which altered the analysis of a doctors obligation. Mrs Pearce, who was expecting her sixth child, was two weeks past her due date of delivery. She discussed the possibility of induction with her obstetrician who warned her of the risks of induction and caesarean surgery, but did not tell her that there was a 0.1 to 0.2 per cent risk of stillbirth associated with non-intervention. Mrs Pearces child was stillborn and she alleged that failure to warn her of the full risks was negligent. Lord Woolf, in this case, held that the patient had the right to know and stated the doctor should normally inform a patient of â€Å"a significant risk which would affect the judgment of a reasonable patient.† It was decided, however, that while a doctor is under an obligation to warn, the 0.1 to 0.2 per cent risk of stillbirth was not classed a significant risk. While the Pearce judgment did not go so far as to fully accept the doctrine of informed consent, it adopted elements of the reasonable test. The judgement goes a certain distance to reconcile the approaches of Lord Scarman, Lord Bridge and Lord Templeman in Sidaway. It isolated Bolam, which by Professor Margaret Brazier,who has wrote many publications on issues of medical law, was considered good as Bolam was â€Å"out of control and out of context, it came close to acquiring democratic status in some quarters.† The test for duty to warn was now suggested to be that the reasonable doctor must tell the patient what a reasonable patient wanted to know. The judgement signified a more patient-friendly approach and made greater demands on the level of disclosure. Chapter 3: Further development towards the doctrine of informed consent 3.1 The medical professional has taken steps to further achieve the full introduction of informed consent into the medical world. The General Medical Council (GMC) produced comprehensive guidance to, doctors on seeking the patients consent in Seeking Patient Consent: The Ethical Considerations February 1999 (appendix I). These guidelines make particular reference to the requirement on doctors to attain informed consent, a doctrine which a few years earlier was alien to English law. Since 1992 Professor Sir Ian Kennedy LLD, a former member of the GMC, has been arguing that doctors need specific guidelines on what constitutes good practice. At that time he was the voice of the minority, however due to dramatic change in the doctor-patient relationship the GMC recognised guidelines needed to be established. The standard adopted in these guidelines resembles elements of the prudent patient test specifically that of the judgment made by Lord Scarman in Sidaway. Guidance from the GMC directs doctors to†¦take appropriate steps to find what patients want to know and ought to know about their condition and its treatment. Andrew Hockton believed that the guidelines, â€Å"should now be considered to amount to more an ethical obligation: they provide at least, a starting-point for measuring the extent of a doctors duty of care to patients† It appears that the guidelines are considered to be a benchmark for doctors to monitor their legal duty of care, to which the Bolam test fails to create. This dissertation professes that perhaps this is the responsible body of medical opinion and it seems the medical profession are setting a higher standard for both themselves and the patient. 3.2 It must be noted the development of the Human Rights Act 1998, has extended the doctrine of informed consent in medical treatment. Incorporation of the European Convention of Human Rights under the Human Rights Act encourages the courts to focus more on the patients rights. This area of law includes Article 2 (the right to life), Article 3 (prohibition on inhuman or degrading treatment) and Article 8 (the right to respect for private and family life which includes the right to bodily integrity). The case R(on the application of Wilkinson) v Broadmoor Hospital illustrates how the introduction of the rights affected certain aspects of medical law. A mental patient appealed concerning a decision to administer treatment without his consent and under restraint. He claimed it infringed his rights under the European Convention of Human Rights 1950, Art.2, Art.3 and Art.8. The judge allowed the appeal stating that under the 1998 Act, it was no longer appropriate to forcible treat detained patients without a court judgement granting so. While the decision in this case would not have been so without the introduction of the Human Rights Act, it had little effect on the majority of medical consent cases. The Act was expected to have a great impact upon issues of medical consent, however it does not seem to have made a dramatic difference on the Courts decision making. 3.3 The most recent case that has dealt with the issue of informed consent is Chester v Afshar, where the claimant underwent surgery and suffered nerve damage leading to paralysis. The surgeon failed to warn Miss Chester of the inherent risk in surgery and the House of Lords decided that the risk was of sufficient quantity to determine the defendant had inadequately warned. The case is considered to show the importance the courts attached to the principle of autonomy, as Lord Hope reiterates when he states, â€Å"the duty to warn has at its heart the right of the patient to make an informed choice as to whether and if so when and by whom to be operated on.† The claimants evidence verified had she been warned of the risk she would not have agreed to surgery without at least seeking a second opinion on the necessity and risks of surgery. Therefore, a causation link was adopted by the courts to further prove negligence by the doctor. 3.4 In this case it was sufficient for her to prove that, if properly warned, she would not have consented to the operation. Dr Afshar was found to violate her right to choose, which meant she was unable to seek further advice or alternatives. Therefore, a claimant pursuing a claim in this area must prove if the information had been given, their decision as to the treatment would have caused extra consideration. Lord Steyn asserted that individuals have a right to make important decisions affecting their lives for themselves†¦in modern law paternalism no longer rules. This case was a ground breaking decision by the House of Lords, as it introduced fully informed consent and it addressed the purpose and rationale behind a doctors duty to warn. 3.5 Historically the law as taken the view that doctors are honourable and true, essentially allowing the medical profession themselves to dictate the duty to disclose. As a result of the decision made in Chester v Afshar this outlook has changed somewhat and it appears to provide a new dawn for patients rights. It has created a remedy for patients who have received insufficient information, where previously the majority of case had failed to provide such a remedy. The days of Lord Denning are long gone, meaning the doctor-friendly Bolam principle has practically been condemned worthless. While the judgement can be seen to address the reality of responsible expectations of society, it seems the judgment leaves the court with a difficult job determining who, between the patient and the doctor, is effectively legitimate when it comes to what information is disclosed. More specifically the outcome is likely to be met with distaste from doctors and there is already evidence of growing concern from within the profession. Despite the doctors concern the law of informed consent has moved on considerably from the reality where the majority of cases would fail to offer a remedy for those who had not been completely informed. As was stated by Sarah Devaney in a Medical Law Review, that back then, â€Å"It did not matter whether or not doctors were wearing the flak jackets of consent, as patients wishing to make claims about lack of information were in any event carrying unloaded guns. However, after cases, time and the materialization of certain events the doctrine of informed consent began to take effect in English law. Chapter 4: The Degree of Sufficient Information 4.1 Informed consent is based on the requirements of appropriate information to allow patients to make an informed choice. The law fails to formulate a standardize figure which can be consider significant and therefore it can only be gauged on previous cases and what the accepted amount has or has not been within these circumstances. More specifically, as no clear indication has been articulated, the judgement will be dependant on the individual facts of the case, as long as this coincides with the authoritative case law. What is clear is that failure to advise sufficiently as to the nature and purpose of the procedure may give rise to an action against the doctor. If the patient is given inadequate information, then how they able to make an informed decision and therefore be said to have given real consent? 4.2 The leading case Chester v Afshar (as discussed above) contradicted any previous beliefs of the court and that of the medical profession. The case prior to Chester was Pearce v United Bristol Health Care (as discussed above) where Lord Woolf stated that the doctor should normally inform a patient of a significant risk which would affect the judgement of a reasonable patient. It considered the balance of percentages and whether this balance would have effected the patients decision to have the treatment. The risk of 1-2 per cent in this case was not considered to be sufficient to represent a significant risk. The decision in Chester made it clear that a 1-2 per cent risk was an adequate percentage for the doctor to warn the patient. Even though, the doctor appropriately informed according to the Pearce decision and the GMC standards, Chester v Afshar brought a new way of thinking to the table. 4.3 Chester disregarded the concept of what a reasonable patient would want to know and instead looked at what each individual patient wanted to know for themselves. This meant it was more plausible for the doctor to consider the patients personality, concerns and wants and information given must be relevant to the patients decision. The involvement of the causation link enabled patients to assert their rights over decision not only on the surgery itself, but in addition on the circumstances in which it was under, for example the time, place and in whose hands the operation should be performed. The causation link made it easier for patients to receive a remedy at law, as long as they could prove that had they been sufficiently warned of the risks they wouldnt have undergone the treatment. This does not mean they need to prove that they would not have had the operation at any time, just not at that moment in time in which they did. The doctor needs to make acknowledgment to both warn of a significant risk and risks which a patient would consider relevant, even if not below significance. It left the doctors with the delicate job of determining what information individual patients wanted to know. This contemporary approach sent shock waves through the medical profession and the GMC had to amend their guidelines, as they now failed to reach a high enough standard. The new guidelines can be found In Good Medical Practice 2006. (see Appendix II) 4.4 Professional guidelines now go further and state the doctor must do his best to discover the patients individual needs and priorities to analysis what information that individual may require. When consenting to treatment patients should be aware of certain factors such as, diagnosis, prognosis, various treatment options, probabilities of success and possible side effects. This was the situation in the case Smith v Tunbridge Wells Health Authority, where a claim was brought against a 28 year old man who was not warned of the risk of impotence inherent in rectal surgery. His claim succeeded despite the risk being considered significantly low, as the judge found failure to warn such a patient of a risk of such importance to him was neither reasonable nor responsible. The doctor needed to have balanced the small risk of importance against the importance it possessed on his life. 4.5 The most effective way of obtaining consent that is currently in the English medical system is consent forms. Consent forms place emphasis on the patients rights; it gives them a sense of control and perhaps recaptures some of the faith that is said to have disappeared between doctors and patients. There is no requirement in English law that consent forms should be in writing, however the Department of Health have recommended the use model consent forms (see appendix III). The most prominent aspect is the fact it does not shy away from informed consent and instead seems to embrace it. It attempts to ensure that patients are aware that they are entitled to ask questions and expect explanations do with the medical treatment they receive. Unfortunately this way of operating is time consuming and is limited to operations and major procedures. It would not be viable for such things as checking a patients throat or examining a patients stomach, as these everyday occurrences are too frequent and considered to be too minor. Some see the consent form as purely evidential yet other believes them to signify fairness to both the patient and the doctor. It creates patient awareness of the fact that they have the right to know and for this right to be attained the patient needs to make it aware what they specifically want to know. This does not extinguish the doctors duties, he must still follow the guidelines set out in obtaining informed consent, for example, explaining the treatment and its implications. In the case Abbas v Kenny the judge stated the obligation is not placed upon the patient and it simply reaffirms their rights, yet it is still the doctors responsibility to â€Å"take into account the personality of the pati ent and the likelihood of misfortune.† 4.6 Even if a warning is given, it can not be consider a suitable warning if it is insufficiently clear to the patient and affects their ability to make a decision on information they fail to comprehend. The doctor must take responsible steps to ensure that advice is understood by the patient. To what extent is it the doctors duty to make sure the patient understands? Chapter 5: A Patients Capability to Understand 5.1 There is a rebuttable presumption that adults have capacity to consent to or refuse treatment. Therefore to make consent valid they must possess the capacity to understanding the method, consequences and benefits. If one fails to understand the information given and the inherent risks of treatment then it can not be regarded as informed consent. Care must be taken to not automatically presume those with learning difficulties are incapable; it is important for doctors to not underestimate a person from their faà §ade. Capacity is not a question of decree of intelligence or maturity of the person concerned, it incorporates elements of ability and belief. 5.2 There are different functions of what must be understood. The must frequently cited case in this context is Re C (Adult: Refusal of Medical Treatment) in which, Thorpe J, held that the person must understand the nature, purpose and effect of the procedure. In other words, sufficient knowledge constitutes the general functions of treatment. Another function that capacity can occupy is that held in Re T (Adult: Refusal of Traetment) where Lord Donaldson referred to knowledge in broad terms of the nature and effect of the procedure to which consent was given. The level of understanding was made important in this case and that this will differ according to the gravity of the decision. More specifically, the more serious a decision the greater capacity required and accordingly patients may have capacity to make some decisions but not others. 5.3 Assessment of a patients capacity is determined by reference to the Thorpe. Js three stage test in Re C it states the courts will assess the patients ability: to take in and retain treatment information; to believe it; to weigh that information, balancing risks and needs. In this case, a sixty-eight-year old patient was being detained in a special hospital, as he survived from schizophrenia. Despite this, the Judge ruled that the patient remained capable of understanding what he was told about the proposed treatment and the proposed risks involved. By satisfying the three points, a patient can verify that information can be given by the doctor, thought through and decided on and therefore the doctrine of informed c

The Yellow Wallpaper

In the story the Yellow Wall Paper, the narrator is making a statement which is saying that if you are locked up in a house or â€Å"prison† you are not being allowed to be put to your full potential with society. She is using the narrator's point of view to show how mental issues start to occur when you are confined to one place and have no actual view of the outside world. That statement also includes the effects of your mind when you can only think to yourself and imagine. The main character's mind starts to go insane when thinking too much into things. Throughout the story the main character looks into every little detail of the room and analyzes it. This is the effect of having too much time on her hands and not having anything better to do. The story is about a woman who's husband sent her away to this house to get mentally better and starts to see this wallpaper. She has very strict rules such as not being able to read or write so she starts looking at this wallpaper. While she's looking at this wallpaper she starts to interpret it in many different ways throughout the story. She's irked by the bright yellow outline that is has, which then turns into her seeing heads being hanged. As the story goes on her views of the room get even worse and it doesn't help that her husband John is treating her like a little girl. Her husband has a wrong view of what is going on in her head. She gets annoyed by the fact that she can't even talk to him about the situation she's in. The story goes on to her doing many irrational behaviors in the room and her anxiety gets worse and worse while getting fed up with everything little thing she notices in the room and about the wallpaper. She is also also a Mother that isn't aloud to be near her baby which adds to her anxiety. Charlotte Perkins Gilman shows a first person point of view with the narrator about how she is feeling â€Å"So I take phosphate or phosphites- whichever it is , and tonics, and journeys, and air, and exercise, and am absolutely forbidden to â€Å"work† until I am well again. Personally, I disagree with their ideas. Personally, I believe that congenial work, with excitement and change, would do me good†(p490). She is able to capture how the narrator is really feeling. The narrator is a housewife that doesn't have a real job. She wants more out of life; she really wants to be able to read and write so that she can put her thoughts to good use and vent. When her husband took her books away from her, she started to read the wallpaper because she likes to read and analyze and is very good at it by the way she describes the room and the wallpaper. She also didn't put up a fight when she was sent away. She develops a mental illness by being a housewife and not being able to go out. When she is put in this psychiatry room, she starts to get worse. She thinks she's getting better later on in the story because her husband tells her that she can have her life back if she gets better. The narrator is disgusted with the room she's in but tries to make the best of it. She really enjoys and desires human interaction. Charlotte Perkins Gilman shows the narrator's loneliness â€Å"When I get really well, John says we will ask Cousin Henry and Julia down for a long visit; but he says he would as soon put fireworks in my pillowcase as to let me have those stimulating people about now†(p. 491). This really shows how she's looking forward to seeing her family to be able to talk about her work. John is her husband who's making all the decisions and holding her back like a child. He doesn't show her much attention because he is always with other patients and often comes to visit her at night. At one point in the story he carried her from one room to another like a baby. That doesn't do her any good because she knows that she's a grown up person and is capable of doing more. By him treating her like a baby makes her feel like a baby, and then continues to more mental issues. John should've treated her like an adult so that she would act more like an adult. Charlotte made him into a controlling character â€Å"He is very careful and loving, and hardly lets me stir without special direction†(p490). This shows how he's controlling the way she does things yet still loves her. She needs more freedom which he doesn't want to give her. He thinks that by putting her in that room she will learn a lesson like a little child and teach herself how to get better. What she really needs is to be able to go out and enjoy what society has to offer her. The room she's in shows what it's like to be deprived by society; the room is like her own little society. She's trying to make the best of it by looking into every little detail of it from the bed to the wallpaper. She wasn't allowed to go out of her house or do anything because John wanted her to be a housewife which is why she started having all of these mental issues. She had to fulfill the duties that John wanted her to do which got boring to a certain point. She is a people's person. Every time that the nurses would come in she always talked to them as if she really knew them. Charlotte Perkins Gilman captures the narrator's thoughts â€Å"I don't like our room a bit. I wanted one downstairs that opened on the piazza and had roses all over the window, and such pretty old-fashioned chintz hangings! â€Å"(p490). She really doesn't like anything about the room she's in. When she looks out her window she sees a lovely country like village full of people which she wishes she could go out and have fun there. Being trapped in a house is the worst thing that is happening to her. She tries to make the best of the situation she's in by thinking into every little thing that annoys her. The room is a symbol of a door that is closed to society. The wallpaper is the main symbol in this story. The narrator starts to see heads that have been hanged which is obvious signs that she is starting to become delusional or insane. The color starts to change from yellow to brown after days of just staring at it. She then starts to see bars on the wallpaper which is representing herself. She feels like she's in a jail cell locked up and is not allowed to have fun or do anything except what John wants her to do. Throughout the story she feels as that it's better for her to be in this room of misery with her baby, so that the baby doesn't have to stare at it all day. She doesn't want her baby â€Å"living in a room full of worlds† which almost signifies the day dreaming that goes on in there. After awhile she starts to look at the positive side of being locked up in that room. The wallpaper whether it was yellow or not, was the main controlling mechanism of the character's mood for story. Her mood no matter day or night was based on the wallpaper she was looking at. The narrator actually asked John during the beginning of her stay to take down the wallpaper since it was causing more nervous trouble, but he didn't. He thought that she was letting it get to her and wanted her to deal with it which is funny because she ended up writing an entire short story about it. The narrator could also be feeling a sense of yellow on the inside. In our world we look as yellow as happy but maybe not as fully. Colors like orange or green are a lot happier. At one point she has a view of a garden which is where she could be picking up some yellow. She even thought there was a yellow smell. The wallpaper effects her so much she feels as if it's getting into her hair. Charlotte Perkins Gilman shows a very good depiction to help create a mental picture of what is going on in the room: â€Å"The color is repellent, almost revolting; a smoldering unclean yellow, strangely faded by the slow-turning sunlight(p. 490)†. She shows great use of vocabulary with words such as repellent and revolting along with imagery which catches her reader's eyes. The title is an example of how the narrator can show her intellectual ability and desire of how she feels like she's in prison. The narrator's ability to interpret the wallpaper and every little detail in the room is unique even though it is a psychiatry case. Charlotte Perkins Gilman uses the narrator's point of view to really capture how she feels towards the wallpaper which in her mind is disgusting and not her type. Almost every paragraph is about something bad pertaining to the wallpaper. Her intellectual ability is to see and analyze things which may be why she gets along with so many people. Charlotte Perkins Gilman gives a great view saying â€Å"He says that with my imaginative power and habit of story making, a nervous weakness like mine is sure to lead to all manner of excited fancies, and that I ought to use my will and good sense to check the tendency†(p. 91). She clearly has a wild imagination that John is trying to cut down. She might be more of a hands on person. Therefore, the wallpaper brings a very different type of analytical approach. Her husband locked her up in this house so she wasn't being put to her full potential. Instead she started looking at the small things in her house while John just wanted her to si t at home and it turned into a mental illness. Towards the end of the story the narrator really started to go crazy walking around the room. She couldn't stand the fact that her bed was nailed to the floor. She ripped off all the wallpaper when nobody was around. She threw the key out of the room so that nobody can come in or out until John arrives. She even found a rope incase Jennie got in she was going to tie her which is a little crazy. The narrator realizes that if she jumps out the window that people will think she's crazy more than she already is. She's a frustrated psychiatric patient just trying to feel better. She's been in there for about a couple weeks. The wallpaper messes with her head a lot. She can't wait to leave the place she's in. She has everything planned out even taking a boat back to town. Her husband comes back for what she thinks is her last day in the psychiatric room. She rips down all of the wallpaper which showed a lot of courage since her nervousness wasn't letting her do anything til she's satisfied. She then takes the key locks the door and throws it out the window so that when John comes in he looks at her and faints. She does nothing but step over him. Charlotte Perkins Gilman shows what is really going on â€Å"I kept on creeping just the same, but I looked at him over my shoulder†(p500). I think she just about had enough with staying in that room and may have even been feeling better since she worked up the courage to do all that and even walk over her own husband. Charlotte Perkins Gilman used a very easy to read type of style which was helpful in figuring out the plot and building a mental image of what was going on. † I have found out another funny thing, but I shan't tell it this time! I mean to try it, little by little. â€Å"(p498). She has a very broad use of vocabulary but not hard enough to need a dictionary to figure things out. It's interesting that she breaks the story into different parts or chapters. The narrator's character changed in each part, mostly because of the other characters or the wallpaper. Her writing style is also modern compared to other stories in this book. This type of writing style is nice. She uses a character with a mental disorientation and captures what is really going through her mind. Her writing flows just like any other short story but even better. She doesn't make it hard to figure the details out. She is very straight forward with the way she words her sentences. I'm wondering if the author wrote this short story to show another person, or if the author herself was the main character in the story. This seem like it could be a realistic story. In this century there are many mentally ill people ranging from anxiety issues to disorders. This could be a true story. The sentences are short and clear but not at all long enough to get lost in them. The story was literally written as the main character was seeing things. It was even broken up from the start of her being in the psychiatric ward included with a two week break from writing for when John kept visiting her in the beginning. Every thought and movement was written down. The Yellow Wallpaper In the story the Yellow Wall Paper, the narrator is making a statement which is saying that if you are locked up in a house or â€Å"prison† you are not being allowed to be put to your full potential with society. She is using the narrator's point of view to show how mental issues start to occur when you are confined to one place and have no actual view of the outside world. That statement also includes the effects of your mind when you can only think to yourself and imagine. The main character's mind starts to go insane when thinking too much into things. Throughout the story the main character looks into every little detail of the room and analyzes it. This is the effect of having too much time on her hands and not having anything better to do. The story is about a woman who's husband sent her away to this house to get mentally better and starts to see this wallpaper. She has very strict rules such as not being able to read or write so she starts looking at this wallpaper. While she's looking at this wallpaper she starts to interpret it in many different ways throughout the story. She's irked by the bright yellow outline that is has, which then turns into her seeing heads being hanged. As the story goes on her views of the room get even worse and it doesn't help that her husband John is treating her like a little girl. Her husband has a wrong view of what is going on in her head. She gets annoyed by the fact that she can't even talk to him about the situation she's in. The story goes on to her doing many irrational behaviors in the room and her anxiety gets worse and worse while getting fed up with everything little thing she notices in the room and about the wallpaper. She is also also a Mother that isn't aloud to be near her baby which adds to her anxiety. Charlotte Perkins Gilman shows a first person point of view with the narrator about how she is feeling â€Å"So I take phosphate or phosphites- whichever it is , and tonics, and journeys, and air, and exercise, and am absolutely forbidden to â€Å"work† until I am well again. Personally, I disagree with their ideas. Personally, I believe that congenial work, with excitement and change, would do me good†(p490). She is able to capture how the narrator is really feeling. The narrator is a housewife that doesn't have a real job. She wants more out of life; she really wants to be able to read and write so that she can put her thoughts to good use and vent. When her husband took her books away from her, she started to read the wallpaper because she likes to read and analyze and is very good at it by the way she describes the room and the wallpaper. She also didn't put up a fight when she was sent away. She develops a mental illness by being a housewife and not being able to go out. When she is put in this psychiatry room, she starts to get worse. She thinks she's getting better later on in the story because her husband tells her that she can have her life back if she gets better. The narrator is disgusted with the room she's in but tries to make the best of it. She really enjoys and desires human interaction. Charlotte Perkins Gilman shows the narrator's loneliness â€Å"When I get really well, John says we will ask Cousin Henry and Julia down for a long visit; but he says he would as soon put fireworks in my pillowcase as to let me have those stimulating people about now†(p. 491). This really shows how she's looking forward to seeing her family to be able to talk about her work. John is her husband who's making all the decisions and holding her back like a child. He doesn't show her much attention because he is always with other patients and often comes to visit her at night. At one point in the story he carried her from one room to another like a baby. That doesn't do her any good because she knows that she's a grown up person and is capable of doing more. By him treating her like a baby makes her feel like a baby, and then continues to more mental issues. John should've treated her like an adult so that she would act more like an adult. Charlotte made him into a controlling character â€Å"He is very careful and loving, and hardly lets me stir without special direction†(p490). This shows how he's controlling the way she does things yet still loves her. She needs more freedom which he doesn't want to give her. He thinks that by putting her in that room she will learn a lesson like a little child and teach herself how to get better. What she really needs is to be able to go out and enjoy what society has to offer her. The room she's in shows what it's like to be deprived by society; the room is like her own little society. She's trying to make the best of it by looking into every little detail of it from the bed to the wallpaper. She wasn't allowed to go out of her house or do anything because John wanted her to be a housewife which is why she started having all of these mental issues. She had to fulfill the duties that John wanted her to do which got boring to a certain point. She is a people's person. Every time that the nurses would come in she always talked to them as if she really knew them. Charlotte Perkins Gilman captures the narrator's thoughts â€Å"I don't like our room a bit. I wanted one downstairs that opened on the piazza and had roses all over the window, and such pretty old-fashioned chintz hangings! â€Å"(p490). She really doesn't like anything about the room she's in. When she looks out her window she sees a lovely country like village full of people which she wishes she could go out and have fun there. Being trapped in a house is the worst thing that is happening to her. She tries to make the best of the situation she's in by thinking into every little thing that annoys her. The room is a symbol of a door that is closed to society. The wallpaper is the main symbol in this story. The narrator starts to see heads that have been hanged which is obvious signs that she is starting to become delusional or insane. The color starts to change from yellow to brown after days of just staring at it. She then starts to see bars on the wallpaper which is representing herself. She feels like she's in a jail cell locked up and is not allowed to have fun or do anything except what John wants her to do. Throughout the story she feels as that it's better for her to be in this room of misery with her baby, so that the baby doesn't have to stare at it all day. She doesn't want her baby â€Å"living in a room full of worlds† which almost signifies the day dreaming that goes on in there. After awhile she starts to look at the positive side of being locked up in that room. The wallpaper whether it was yellow or not, was the main controlling mechanism of the character's mood for story. Her mood no matter day or night was based on the wallpaper she was looking at. The narrator actually asked John during the beginning of her stay to take down the wallpaper since it was causing more nervous trouble, but he didn't. He thought that she was letting it get to her and wanted her to deal with it which is funny because she ended up writing an entire short story about it. The narrator could also be feeling a sense of yellow on the inside. In our world we look as yellow as happy but maybe not as fully. Colors like orange or green are a lot happier. At one point she has a view of a garden which is where she could be picking up some yellow. She even thought there was a yellow smell. The wallpaper effects her so much she feels as if it's getting into her hair. Charlotte Perkins Gilman shows a very good depiction to help create a mental picture of what is going on in the room: â€Å"The color is repellent, almost revolting; a smoldering unclean yellow, strangely faded by the slow-turning sunlight(p. 490)†. She shows great use of vocabulary with words such as repellent and revolting along with imagery which catches her reader's eyes. The title is an example of how the narrator can show her intellectual ability and desire of how she feels like she's in prison. The narrator's ability to interpret the wallpaper and every little detail in the room is unique even though it is a psychiatry case. Charlotte Perkins Gilman uses the narrator's point of view to really capture how she feels towards the wallpaper which in her mind is disgusting and not her type. Almost every paragraph is about something bad pertaining to the wallpaper. Her intellectual ability is to see and analyze things which may be why she gets along with so many people. Charlotte Perkins Gilman gives a great view saying â€Å"He says that with my imaginative power and habit of story making, a nervous weakness like mine is sure to lead to all manner of excited fancies, and that I ought to use my will and good sense to check the tendency†(p. 91). She clearly has a wild imagination that John is trying to cut down. She might be more of a hands on person. Therefore, the wallpaper brings a very different type of analytical approach. Her husband locked her up in this house so she wasn't being put to her full potential. Instead she started looking at the small things in her house while John just wanted her to si t at home and it turned into a mental illness. Towards the end of the story the narrator really started to go crazy walking around the room. She couldn't stand the fact that her bed was nailed to the floor. She ripped off all the wallpaper when nobody was around. She threw the key out of the room so that nobody can come in or out until John arrives. She even found a rope incase Jennie got in she was going to tie her which is a little crazy. The narrator realizes that if she jumps out the window that people will think she's crazy more than she already is. She's a frustrated psychiatric patient just trying to feel better. She's been in there for about a couple weeks. The wallpaper messes with her head a lot. She can't wait to leave the place she's in. She has everything planned out even taking a boat back to town. Her husband comes back for what she thinks is her last day in the psychiatric room. She rips down all of the wallpaper which showed a lot of courage since her nervousness wasn't letting her do anything til she's satisfied. She then takes the key locks the door and throws it out the window so that when John comes in he looks at her and faints. She does nothing but step over him. Charlotte Perkins Gilman shows what is really going on â€Å"I kept on creeping just the same, but I looked at him over my shoulder†(p500). I think she just about had enough with staying in that room and may have even been feeling better since she worked up the courage to do all that and even walk over her own husband. Charlotte Perkins Gilman used a very easy to read type of style which was helpful in figuring out the plot and building a mental image of what was going on. † I have found out another funny thing, but I shan't tell it this time! I mean to try it, little by little. â€Å"(p498). She has a very broad use of vocabulary but not hard enough to need a dictionary to figure things out. It's interesting that she breaks the story into different parts or chapters. The narrator's character changed in each part, mostly because of the other characters or the wallpaper. Her writing style is also modern compared to other stories in this book. This type of writing style is nice. She uses a character with a mental disorientation and captures what is really going through her mind. Her writing flows just like any other short story but even better. She doesn't make it hard to figure the details out. She is very straight forward with the way she words her sentences. I'm wondering if the author wrote this short story to show another person, or if the author herself was the main character in the story. This seem like it could be a realistic story. In this century there are many mentally ill people ranging from anxiety issues to disorders. This could be a true story. The sentences are short and clear but not at all long enough to get lost in them. The story was literally written as the main character was seeing things. It was even broken up from the start of her being in the psychiatric ward included with a two week break from writing for when John kept visiting her in the beginning. Every thought and movement was written down.

The Jealous Heathcliff of Wuthering Heights Essay

The Jealous Heathcliff of Wuthering Heights Throughout Wuthering Heights, Heathcliffs personality could be defined as dark, menacing, and brooding. He is a dangerous character, with rapidly changing moods, capable of deep-seeded hatred, and incapable, it seems, of any kind of forgiveness or compromise. In the first 33 chapters, the text clearly establishes Heathcliff as an untamed, volatile, wild man and establishes his great love of Catherine and her usage of him as the source of his ill humor and resentment towards many other characters. However, there are certain tensions, contradictions, and ambiguities present in Chapter 34 that establish the true intensity Heathcliffs feelings towards Catherine; feelings so†¦show more content†¦He refuses to eat, absents himself from the company of Cathy, Hareton, or Nelly, disappears inexplicably for long intervals of time and refuses to explain his absences. Most disturbing, his strange excitement continues, causing discomfort to all those around him, especially Ne lly. When Nelly asks him where he was the night before his he began to exhibit this odd elation, he tells her, Last night, I was on the threshold of hell. To-day I am within sight of my heaven -- I have my eyes on it -- hardly three feet to sever me (278)! His statement is ambiguous--it does little to explain his sudden change of humor and little to satisfy Nellys curiosity and wonder at his state. Joy in most characters in Wuthering Heights is an uplifting state associated with happiness and delighted exhilaration. However in Heathcliff, as Nelly observes, it is a horrible, frightening thing. In Heathcliff, the mood arouses wariness and fear in others and indicates some inner change so dramatic that its cause is almost unthinkable. 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4th Grade Science Quiz