Ethical and Legal Issues in Psychiatry

Question 1

What are the two arguments justifying overruling refusal of treatment?
Which approach does English law take?

Answer 1

1. Argue that the illness interferes with their normal values - so respecting the patient’s autonomy is to respect what that epson wants when free from depressive illness
2. Argue that it is right because it is in their best interests (and others) to do so and they are suffering from a mental illness
   - English law takes the second approach, at least about the treatment of the mental (not the physical) illness

Question 2

What is the difference between the mental health act the mental capacity act?

Answer 2

• A person can be treated for a mental disorder under the MHA without reference to their capacity.
• allows a competent patients refusal to be overruled
• gives society much wider powers forcibly to restrain, for the protection of others, mentally disordered people compared to those without mental disorder
• e.g. dangerous mentally ill can be detained almost indefinitely
  But those without a mental disorder cannot be kept n a secure place, however dangerous they are thought to be, if they have either not yet committed a crime OR have served their prison sentence

Question 3

A person can be treated for a mental disorder under the MHA without reference to their capacity.
- What are the ethical problems with this approach?

Answer 3

• override a competent patients refusal:
• either it assumes that the presence of a mental illness automatically renders someone incompetent (false) OR it simply discriminates between the physically and mentally ill
• protection of others as well as the patient not usual in physical disorders to be treated for someone else’s sake

Question 4

The question of ………. is central to overriding refusal for the sake of the person himself

Answer 4

capacity

Question 5

• The main method by which society protects itself from those dangerous to others is through the ………. ………….
• It may be inappropriate to use the criminal law in the case of some mentally ill - they are not ……….. for their dangerous acts
• The central issue in the case of dangerousness to others is not capacity but …………….

Answer 5

criminal law
responsible
responsibility

Question 6

What are the 3 routes to compulsory admission under the MHA?

Answer 6

Section 2 = admission for assessment
Section 3 = admission of treatment
Section 4 = admission for emergency assessment

Question 7

What are the grounds for admission under section 2 of the MHA?
- how long does it last?

Answer 7

Admission for assessement
- mental disorder = nature/degree which warrants detention - assessment
AND
- dangerous
- application by nearest relative or social worker
- lasts for 28 days

Question 8

What are the grounds for admission under section 4 of the MHA?
How long does it last?

Answer 8

Emergency Assessment 
Grounds are the same as section 2
 - mental disorder = nature and degree which warrant detention 
AND 
dangerous
Application only by 1 DR
72 hours

Question 9

What are the grounds for admission under section 3?

How long does it last?

Answer 9

ADmission for treatment
- mental disorder degree/nature and dangerous
AND
- mental illness treatable = alleviate or prevent deterioration in mental illness
- treatment includes symptoms
- application similar to S2 - although where SW makes the application NR must be consulted
- 6 months but renewable
- cannot be used to enforce treatment on an out-patient basis

Question 10

What amendments were made to Section 1 in the MHA?

Answer 10

Section 1 = removal of categories of mental disorder

• from ‘mental illness, arrested or incomplete development of mind, psychopathic disorder and any peer disorder or disability of mind’
• –> ‘any disorder of disability of the mind’

Question 11

What amendments were made to Section 4 in the MHA?

What loophole did this close?

Answer 11

• Section 4 introduces a new ‘appropriate medical treatment test; into the criteria for detention under section 3 of the 1983 act and corresponding criteria for renewal and discharge
• the effect is that these criteria cannot be met unless medical treatment is available to the patient in question which is appropriate taking account of the nature and degree of the patients mental disorder and all other circumstances of the case
• closed the loophole of detaining untreatable personality disorders

Question 12

What amendements were made to the role of the responsible medical officer and approved social worker?

Answer 12

• responsible clinician

- approved mental health professional

Question 13

What safeguards are in place for patients?

Answer 13

section 23 introduces a new right for a patient ot apply for an order displacing the NR on the same grounds available to other aplpplciants on the grounds that the NR is unsuitable to act as such
- prevents abusive relationships

Question 14

What is the only mental health treatment that patients can give an advanced refusal for?

Answer 14

ECT - electroconvulsive therapy

Question 15

What do supervised community treatments allow?

Answer 15

allow some patients with a mental disorder to live in the community whilst still being subject to powers under the 1983 act.

• only those patients who are detained in hospital for treatment will be eligible to be considered for SCT
• in order for a patient to be placed on SCT, arrows criteria need to be met

Question 16

CASE:

• Who has the right to refuse treatment even if life saving?
• Do they need an explanation, rational or otherwise?
• This repeats the individuals right to …………
• Capacity should be ……….. unless proven otherwise by …………… …………..
• ………… is no longer a criminal act

Answer 16

• only competent patients
• no
• autonomy
  assumed, functional assessment t
• suicide

Question 17

What is required for someone to have cacpity?

Answer 17

• take in and retain information
• understand that information (in appropriate terms)
• weigh up the information to arrive at a decision
• communicate that decision

Question 18

When should MCA be used and when would MHA be used?

Answer 18

• initial guidance was to used MCA in the first instance as the ‘least restrictive’ option compared with MHA
• subsequent case law reversed the guidance
• where a patient met the criteria for mention under the MHA and lacked capacity the MHA had to be used
• however this has been complicated by other judgements

Question 19

What issues did the famous surgeon highlight?

Answer 19

• surgical team want to amputate leg, patient refuses to consent, believes that he is a surgeon and than an operation is not necessary
• physicians and surgeons often ask about ‘sectioning’ patients with longstanding mental illnesses who refuse they suggested treatments
• courts find.. in favour of the patient on the grounds that he was competent to refuse treatment
• that ruling has informed MCA - patients no longer have to believe the information given to them

Question 20

What issues did the oldest profession highlight?

Answer 20

Patient with mental disorder but currently well with medication

• Is leaving ward to work as a prostitute
• she appears to be competent to decide on her own actions after discussions with ward staff about risk issues

Question 21

How did the Micheal Stone case lead to the amendment of the MHA?

Answer 21

• He was not treatable and therefore not detainable
• Went on to kill 3 people
• ## Can now detain someone before criminal act

Question 22

What were the 3 amendments of the 1983 Act?

Answer 22

• broadened definiction of mental disroders
• removal of exclusions
• appropriate treatment test