Defining restraint
 
 定义
 
The New Shorter Oxford English Dictionary defines restraint as 'deprivation or restriction of liberty or freedom of action or movement'. Restraint may occur in the following ways:

In a physical manner as in the manual restraint of one individual by others;
By the use of apparatus such as cot-sides to keep a person within a defined area;
By means of medication that may reduce an individual's capacity for freedom of movement.
In subtle ways, such as by reducing the heating in certain rooms within a care setting to discourage the use of these areas at specific times.
Similarly, if a patient requires a walking aid in order to be mobile, removal of the appliance from the patient's reach would be form of restraint. 
 《新牛津简明英语词典》对约束的定义是：“剥夺或限制行动或活动自由”。约束通常表现为：

身体约束：他人对某个个体的身体约束；
器械约束：如采用床栏之类的设备将人限制在一定区域内；
药物约束：通过使用药物减少个体的自由或活动能力；
技巧性约束：通过巧妙方法，如减少护理区内特定房间的暖气，促使人们不去使用这些区域。
如果一个病人的行走需要一些辅助用品，那么，故意将这些用品放到病人拿不到的地方，这也是一种约束。
An attempt by an individual, or group of individuals, to restrain a person is legally justifiable in certain situations, for example to prevent someone committing a crime. In such instances the minimum means of restraint should be used. The restraint of an individual outside such extenuating circumstances, or the use of excessive force, is unjustifiable. Therefore, it is important, from a legal and moral perspective, to ensure that nursing practice does not involve the unjustifiable restraint of patients.
 
 个人或一群人约束某个个人，这在特定情况下是合法的，如防止其犯罪等。在这些情况下，应该使用最起码的约束手段。若个人约束超出这种范围，或是过度使用武力，这就是不正当。因此，从法律和道德角度看，重要的是要确保护理实践不涉及不正当的病人约束。
 
When might it be considered justifiable to restrain an adult within a health care setting? The right of individuals to freedom is based upon the principle of autonomy: people have the right to make their own decisions, which should be respected by others.
 
 那么，护理部门在什么情况下约束成年病人才是正当的呢？个人的自由权是以自主性原则为基础的：人们有自己作出决定的权利，这种权利应得到他人的尊重。
 
Autonomy is often described as a prima facie principle; this means that, at first sight, the principle appears to be one that should be respected by others. However, further examination may reveal other ethical principles that have an equal, or greater, case for recognition.
 
 自主性常常被描绘成是一个“当然原则”，也就是说，人们一眼就可以看出，这个原则是属于应该受到他人尊重的。然而，通过进一步考察就会发现，另外还有一些道德准则，他们同样甚至更需要大家的认同。
 
The ethics of restraint
 
 约束的道德性
 
The following example illustrates the application of ethical principles in practice.
 
 让我们举例说明道德准则在实践中的应用。
 
Anne Martin (not her real name) is 87 years old and has senile dementia. She has been a resident in a care setting for older people for three years, after becoming unable to cope at home because of short-term memory loss and confusion. Her state of mind had resulted in potentially dangerous behaviour, such as wandering from her home and becoming lost, being unaware of traffic hazards when crossing roads and forgetting to eat or drink for several days at a time. In the residential care setting she has attempted to wander outside and, for this reason, a baffle lock is in place at the end of the corridor that leads from her living area to the exit. Although Ms Martin continues to wander, she is unable to leave the premises.
 
 安尼·马丁，87岁，患有老年痴呆症。因短暂性失忆和意识混乱在老年护理院住了三年。她的精神状态已导致其作出了一些有潜在性危险的行为，如离家出走、迷路、过马路时无交通危险意识、连续几天忘记吃喝等。在住家护理院时也试图外出，因为这个原因，在她起居室通往出口的走廊里设置了障碍板。虽然马丁女士继续漫游，但已经无法离开这一区域。
 
While this situation may not be viewed as constituting restraint in the same way that a nurse physically holding on to Ms Martin might be, the arrangement of the environment nonetheless ensures Ms Martin's containment within a restricted area. We may question whether this is justifiable and the following discussion provides one example of how the situation might be examined.
 
 与护士抓住马丁女士身体相比，这种情形可能并不构成约束，但这种环境安排却将马丁女士禁闭在约束区内。我们也许会问，这样做是否正当？下面的讨论为我们如何审查这种情况提供了一个例子。
 
The presence of a baffle lock appears to override Ms Martin's autonomy. However, it may be argued that while autonomy constitutes a prima facie ethical principle, in certain circumstances it may be superseded by other principles. It can be argued that in order for an individual to be autonomous, they must possess insight into the potential or actual consequences of their actions. Ms Martin's dementia interferes with her insight and it may be considered acceptable to override her autonomy by reference to the principle of non-maleficence - the requirement to prevent harm. If Ms Martin is allowed to wander out of the care setting she may encounter hazards such as traffic and suffer harm as a result. Interference with her autonomy may be seen as justifiable on this basis.
 
 设置障碍似乎践踏了马丁女士的自主性。不过，也可以这样说，当自主性成为“当然的道德准则”时，在一定情况下，它是可以被其他原则超越的。可以这样说，为了使一个人获得自主，他就必须具备洞察行动或实际后果的能力。马丁女士的痴呆症妨碍了她的洞察力，因此，根据无罪原则，践踏她的自主性可以认为是可取的，因为这是防止伤害的需要。如果允许马丁女士走出护理区，她就可能遭受危险，如交通事故，并最终造成伤害。因此可以说，干涉她的自主性是正当的。
 
Furthermore, it is arguable that in care settings, there is an ethical requirement not only to avoid harm, but also to create benefit for the client. This principle is beneficence and may also be used to justify restricting Ms Martin's freedom of movement. It may be considered beneficial for Ms Martin to remain within the care environment, in order to maintain both her physical safety and her psychological well-being, because unfamiliar surroundings may cause her distress. The ethical principles of non-maleficence and beneficence might be used as justifications for overriding her autonomy.
 
 再者，在护理环境中，还有一个道德要求问题，就是不仅要避免伤害，而且要为病人带来好处。这就是有利原则，也可以用来说明限制马丁女士活动自由的正当性。可以认为，马丁女士留在护理环境中是有好处的，这既是为了保证她的人身安全，也是为了保持她的精神健康，因为陌生环境可能给她带来痛苦。道德的无罪和有利原则可以用来证明践踏自主性的正当性。
 
Legal aspects of restraint
 
 约束的法律问题
 
The another relevant ethical principle is that of justice. The purpose of justice is to ensure that individuals receive that to which they are entitled or deemed to deserve. It may be argued that the restriction of Ms Martin's freedom is unjust. Older adults with senile dementia present problems that are not addressed fully by the UK mental health legislation. Unless Ms Martin is held as an involuntary patient under a section of the relevant act, she is legally entitled to leave the care setting if she so desires. Any attempt to impede her constitutes an illegal restriction of her liberty.
 
 另一个相关的道德原则是公正原则。公正的目的是要确保个人得到有权得到的或被认为是该得的东西。也许有人会说，限制马丁女士的自由是不公正的，英国精神健康法并没有充分说明老年痴呆者的问题。如果马丁女士不属于相关法律条款所说的“无意识病人”，那么，从法律上讲，如果她愿意，她就有权离开护理区。任何阻碍企图都构成了对她自由权的非法约束。
 
In England, the Bournewood judgement (named after the hospital where the issue arose) by the Court of Appeal in 1998 ruled that patients who lacked the capacity to consent to admission could not be detained within a care setting unless sectioned under the Mental Health Act.
 
 1998年，上诉法庭伯恩伍德审判栽定，护理机构不能收留无能力作出同意入院表示的病人，除非她是属于精神健康条例规定的人。
 
Before the Court of Appeal decision it was assumed that people lacking the mental capacity to make an informed choice (people with severe learning difficulties or dementia, for example) could be considered to be content with their admission - as long as they did not show signs of wanting to 'opt out' of treatment. If they were not actively opting out, then it was acceptable for them to be detained in hospital and be treated without a formal detention under a section of the Mental Health Act.
 
 在上诉法庭判决前，人们都认为，缺乏知情选择心理能力的人(如患有严重学习困难或痴呆的人)，只要没有明显的“决定不参加”治疗表示，他们的住院就可以当作是经其同意的。如果他们没有主动决定不参加，那么，根据精神健康条例，将他们留在医院进行治疗，即使没有正式收留，都是可以的。
 
The Law Lords looked at two main questions: was the person involved actually detained and, if he or she was detained, was the detention lawful?
 
 高级法官考察了两个主要问题：患者是否被实际收留；如果是，这种收留是否合法？
 
However, this judgment was subsequently overturned by the House of Lords, on the basis of the common law principle of 'necessity', by which health care staff are able to act in the best interest of an individual who would otherwise experience significant pain and suffering.
 
 不过，上议院却根据不成文法中的“必需”原则推翻了这种审判。根据这一原则，在个人可能遭受重大危险和痛苦的情况下，保健护理人员可以采取行动保护个人的最大利益。
 
There is a problem for the care team because, while restraint of Ms Martin may constitute an infringement of her legal right to freedom of movement, permitting her to wander - in the knowledge that she may come to harm - could constitute negligence. In order for a charge of negligence to be upheld in law, the following three conditions must prevail:

A duty of care must exist. Within an officially designated care setting staff do owe a legal duty of care to patients/residents;
The duty of care must have been breached. It is arguable that, since staff are aware that Ms Martin has a diminished sense of danger, they should ensure that she does not wander unattended. In the event of her coming to any harm the staff would be viewed as having neglected their duty of care to Ms Martin;
Significant harm must have been sustained as a direct consequence of the neglect of the duty of care. 
 不过，护理小组也会面临一个问题，限制马丁女士的自由可能构成对行动自由这一合法权利的侵犯，允许她出走—-在明智其可能受到伤害的情况下—-又可能构成过失。但是，要使过失指控在法律上成立，就必须满足下列三个条件：

存在护理义务。在正式指定的护理机构内，护理人员在法律上有义务护理病人/居住者；
护理义务未被履行。既然护理人员知道马丁女士危险感下降，他们就应该确保她不会在没人陪同的情况下外出。如果她受到伤害，就可以认为，护理人员忽略了对马丁女士的护理义务。
重大伤害必须是忽略护理义务的直接后果。
For the care team Ms Martin's situation presents a dilemma. On the one hand she is legally entitled to leave the premises and any effort to physically restrain her may be regarded as assault, while on the other hand if she leaves the premises and comes to any harm the staff may be guilty of negligence.
 
 马丁女士的情况使护理人员处于两难境地。一方面，马丁女士有离开上述区域的合法权利，对马丁女士的任何人身约束都可以被看作是侵犯；另一方面，如果她离开上述区域受到伤害，这就是护理人员的失职。
 
The best option is probably to justify the restriction of Ms Martin's autonomy in the light of her diminished insight into the potential consequences of her actions. The care team may argue that the purpose of the baffle lock is to prevent harm and that they are acting in what they perceive to be Ms Martin's best interests.
 
 最好的办法也许是，在马丁女士对其行动潜在后果认识能力下降的情况下，将自主性约束合法化。护理小组可以表明，设置障碍的目的是要防止伤害，他们的行动就是为了最大限度地保护马丁女士的利益。
 
Further issues
 
 几点思考
 
There are other aspects of the situation which have to be taken into account:

The use of a baffle lock may be acceptable in order to ensure Ms Martin's safety, but not if the purpose of its installation is to allow management to reduce staffing levels;
Optimum staff-to-resident ratios would permit a member of staff to accompany Ms Martin in order to ensure that she does not come to any harm when she wishes to leave the premises;
Another consideration is that Ms Martin is not the only resident whose freedom may be restricted by the presence of the baffle lock. The needs of other residents should also be taken into account before using this measure. Such an assessment may be carried out using the same ethical principles that helped to determine whether the restraint of Ms Martin was justifiable;
In areas where baffle locks are justifiable, a written policy and procedure should be formulated by management to explain to staff, residents and their visitors the rationale for the use of the locks. This should also clearly identify the measures that should be taken to ensure that residents who do not need this form of protection are able to leave and enter the area as they please. 
 还有几个方面问题必须加以考虑:

为保障马丁女士的安全，可以使用障碍。如果只是为了减少护理人手便于管理，就不得设置这种障碍；
最佳护-患比允许一位护理人员陪伴马丁女士，以确保她想要离开上述区域时不会受到伤害；
另外也要考虑到，马丁女士并不是唯一的自由受限患者。在采用这一手段时，也应考虑其他患者的需要，可以应用相同的道德准则进行评估，这些道德准则有助于确定约束是否公正；
在障碍合法的地方，应由管理部门制订正式规章和程序，向护理人员、患者及探访者说明使用障碍的原因，同时，明确措施，确保无需这种保护的患者能自由地离开和进入。
Conclusion
 
 结论
 
This case study demonstrates that restricting a person's movements may not concur with commonly held perceptions of restraint as comprising dangerous behaviour on the part of the individual being restrained or those who are in a position to restrain.
 
 本案例研究证明，当受约束者或约束者出现危险行为时，限制个人活动就已不再是大众所认为的那种约束了。
 
It should also have highlighted the complex situations in which restraint may be required and the ethical principles that may be applied to support or discourage its use.
 
 这也已经强调了导致约束的情况的复杂性，说明道德准则既可以用于支持也可以用来反对使用约束。