Coercion in mental health care Flashcards
Why is the power to detain a person for assessment and treatment of their “mental disorder” almost unique amongst doctors (including psychiatrists) in England?
There are powers to detain people suffering from infectious diseases, but they can’t be treated against there will - unless they lack decision-making capacity
What are the stages of treatment decisions in England and Wales?
- Approved clinician (legal status) - responsible clinician
- Second Opinion Appointed doctor (SOAD)
- statutory review: does the patient lack capacity or disagree? (if no -> requires changes)
+ Approved mental health professional
-> If these 3 professionals agree on the assessment and the statutory form, the patient can be detained and treated against his/her will (= compulsory treatment) - The detained patient can make an appeal to the Mental health tribunal (MHT) -> tribunal doctors
- Statutory criteria met?
- if yes: patient stays detained and treated (=compulsory treatment)
- if no: patient is discharged
What are the SOAD and tribunal doctors for?
An independent oversight, from the approved clinician initiating the detention and compulsory treatment, towards the patient.
What are the two views on compulsory treatment in mental health care?
> Supporter: compulsory treatment is potentially a good thing BUT a balance must be struck between “the rights of an individual […] and the need to protect the individual and society at large from the adverse effects of mental disorders.”
Puri et al. (2005): textbook on mental health law
> Opponent: compulsory psychiatric treatment is slavery… Human Rights abuse
- “No one ought to be deprived of liberty except for a criminal offence, after a trial by jury guided by legal rules of evidence… No one ought to be detained involuntarily for a purpose other than punishment.”
Szasz (1998)
What are two Historical precedent of abuse with documentary evidence?
> Nazi Germany: Aktion T4 killed a minimum of 70,000 hospital inmates
- translation: “patients who are considered incurable, can be granted mercy death, after a definitive diagnosis.”
Hitler (1939)
> Soviet Union: psychiatry to suppress dissidence
- translation: “60,000 Reichsmark is what this person suffering from a hereditary defect costs the People’s community during his lifetime. Fellow citizen, that is your money too.”
New people - a magazine published by the Nazi Party (1938)
What are two views from the 1800s on compulsory treatment in mental health care?
> Supporter: Journal of Mental Science (1898)
- “The public should be clearly instructed that the annually recurring and possibly increasing horrors from the crimes of “Lunatics at Large” are the price it pays, under the existing lunacy law, for protection from an illusory danger to the “liberty of the subject””
> Opponent: 1845 manifesto from the Alleged Lunatics Friend Society
- “For the protection of the British
What are the four ethical principles underlying health care according to Beauchamp and Childress?
- Autonomy: no intervention without consent
- strong judicial principle
- involuntary treatment strikes a balance between autonomy and beneficence - Beneficence : do good
- good who whom? - Non-maleficence: first, do no harm
- Justice: fair shares for all
- equity -> how do we allocate scarce resources
e.g. decisions by NICE about supported and non-supported interventions
(National Institute for Health and Care Excellence)
What are the 6 degrees of the “Coercion Spectrum”, 1 being the highest and 6 the lowest?
- Compulsion
- “the law says you must do this”
- “you are detained under Section 3 of the Mental Health Act” - Coercive threats
- “if you don’t do this, I will do that”
- “if you don’t come into hospital we will section you”
(to section = to detain) - Vague threats
- “if you don’t do this, that will happen”
- “if you stop your medication you will be coming back to hospital” - Inducements
- “if you do this, you will get that”
- “if you take your treatment we can support your move on, to your own flat” - Interpersonal leverage
- waiting to please someone who you value
- “trust me on this - give it a try…” - Persuasion
- appeal to reason
- legitimate
- “here is the evidence for you to make sure on your own”
How does paternalism “justifies” coercive interventions?
An action - supposedly legitimate - by the state where a person lacks capacity.
This action must be in the person’s “best interests”.
How does public safety “justifies” coercive interventions?
Actions to prevent harms by a person to others who is deemed to be dangerous (usually after some form of judicial assessment).
This can extend to preventing a person from harming themselves.
What are the European Conventions of Human Rights (ECHR) (1950)?
What kind of Rights do they provide?
What is the condition for interference with ECHR?
What is the role of the Human Rights Act (1998)?
Conventions which the UK has been signed up to since 1951. > They provide Rights that are: - Absolute: e.g. protection from torture - Limited: e.g. right to liberty - Qualified: e.g. freedom of expression
> Interference with ECHR must demonstrate ‘Proportionality’
- “it is necessary in a democratic society, which means it must fulfil a pressing social need, pursue a legitimate aim and be proportionate to the aims being pursued.”
> Human Rights Act (1998) formally incorporates the ECHR into UK Law
- all public authorities in the UK must follow the HRA, thus the ECHR
Which Articles (Rights) of the Human Rights Act (1998) are linked to mental health care?
> Article 2: Right to life
- mental health services have an operational duty to ensure a patient’s right to life is not breached
- suicide is a potential breach of that right
> Article 3: Prohibition of torture
- no one shall be subjected to torture or to inhuman or degrading treatment or punishment
> Article 5: Right to liberty and security
- legitimates deprivation of liberty in specific circumstances - subject to local judicial scrutiny
> Article 6: Right to a fair trial
> Article 8: Right to respect for a private life and family life
- compulsory treatment and a numerous other aspects of hospital care profoundly affect this right
e. g. detention
What does the Article 5 (1) (e) of the Human Rights Act (1998) say?
What does it imply regarding the Right to liberty and security?
What is the principle in this article?
Article 5: Right to liberty and security
Article 5 (1) (e): "the lawful detention of persons for the prevention of the spreading of infectious diseases, of persons of unsound mind, alcoholics or drug addicts or vagrants"
-> When we detain, we take away the Right to liberty and security.
Key principle: detention is subject to legal scrutiny
What are the major changes in the evolution of mental health legislation in England and Wales?
> Lunacy Act (1890)
- close textured law
- appropriate admission
- overseen
> Mental Treatment Act (1930)
- informal admission
- community care
> Mental Health Act (1959)
- compulsory admission and treatment under professional control
- Mental Health Review Tribunals - legal forum to ensure lawful detention
> New Mental Health Act (1983)
- increased safeguards for patients
- consent provision
> Patients in the Community (1995)
- Post-Clunis
- Section 25A
> Mental Health Act (2007)
- Community Treatment Orders (CTOs) (amended the Section 25A)
- broad definition to mental disorder
- technical changes to the law: appropriate Treatment, deprivation of liberty safeguards
When observing the evolution of mental health legislation in England and Wales, what can be said about the law?
The law reflects the concerns of society at the time.
There are variations of a common theme (e.g. Mental Health Act amended three times from the initial one of 1983 to the current one in 2007).
