Ethical issues in long-term psychiatric management

Two general ethical problems in psychiatry are thrown into sharp relief by long term care. This article discusses each in turn, in the context of two anonymised case studies from actual clinical practice. First, previous mental health legislation soothed doubts about patients' refusal of consent by incorporating time limits on involuntary treatment. When these are absent, as in the provisions for long term care which have recently come into force, the justification for compulsory treatment and supervision becomes more obviously problematic. Second, Anglo-American law does not normally allow the preventive detention of someone who may be dangerous but has not actually committed any crime. The justification for detaining a possibly dangerous user of mental health services without his or her consent can only be based on risk assessment, but this raises issues of moral luck. Is the psychiatrist who decides not to take out a supervision order for a possibly dangerous patient with an initial psychotic diagnosis morally at fault if that person harms someone in the community, or himself? Or is the psychiatrist merely unlucky?

Almost a revolution: an international perspective on the law of involuntary commitment

To what extent have developments in commitment law around the world paralleled trends in the United States in the last three decades? Although the American emphasis on dangerousness criteria and strigent procedural rights has been echoed in a number of other countries, it has not dominated reform in most nations. The leading alternative has been the 1983 Mental Health Act in England and Wales, with its focus on the "health and safety" of the patient, as well as protection of other persons, and its avoidance of judicial hearings. How have these reforms fared? Extensive data from the United States, and more limited data from other countries, suggest that reforms in general are resisted when they are seen as shifting the focus away from patients' treatment needs. When law fails to reflect widely held moral sentiments, it is molded in practice to conform more closely to those sentiments. It is helpful to recognize that a variety of approaches to mental health law are consistent with reasonable protection of civil liberties in a democratic society. Greater attention to practices in other countries may help reformers expand the menu of options in policy debates.

The nurse's role as patient advocate for mentally ill people

The recent report of the Confidential Inquiry into Homicides and Suicides by Mentally Ill People (the Boyd report) compiled for the government, and the imminent publication of the Mental Health Patient's Charter, highlight national concern over the provision of care for this group of people. This article examines some of the dilemmas facing mental health nurses when caring for patients under detention orders and evaluates guidelines and recommendations which can aid the nurse in providing appropriate care.

Why do so few patients appeal against detention under Section 2 of the Mental Health Act?

OBJECTIVE

To determine why most patients do not exercise their right of appeal against detention under section 2 of the Mental Health Act 1983.

DESIGN

Part one--retrospective analysis of the clinical notes of patients detained under section 2 of the Mental Health Act. Part two-interviews with patients on the penultimate day before the deadline for lodging an appeal.

SETTING

In part one, five districts in the Oxfordshire Regional Health Authority. In part two, six hospitals from three districts in the region.

SUBJECTS

In part one all patients detained under section 2 in the five districts in 1993 (n = 418). In part two interviews with 40 patients detained under section 2 in the six hospitals.

RESULTS

Patients were more likely to appeal if they were educated to A level standard (odds = 2.26; P = 0.0014) or had had a previous admission (2.19, P = 0.0029). Patients with a diagnosis of depression (0.31; P = 0.0.15) or dementia (0.0003, P = 0.0001) were less likely to appeal. Compared with those who appealed (n = 12) those who did not (n = 28) showed less understanding of their rights (P = 0.034) and poorer comprehension of sentences from the booklet describing patients' rights (P = 0.057). The main reasons given for not appealing were not being aware of the appeals process and being deterred by having to appeal in writing. After they received a full explanation of their rights 12 of those who did not appeal said that they wished to appeal and four did so within the time remaining before the deadline. Of 40 patients, 39 said there should be an automatic right of appeal.

CONCLUSIONS

The appeals procedure against detention under section 2 of the Mental Health Act is not a satisfactory way of protecting the civil liberties of patients. If patients were fully informed of their rights they would probably be much more likely to appeal.

Withholding consent to lifesaving treatment: three cases

The refusal of children or their parents to consent to treatment that professionals regard as essential always results in a dilemma. Responding to such refusals demands careful and sensitive clinical and thicolegal intervention and close cooperation among professionals, in particular doctors and social workers. Since the introduction of the Children Act 1989 the number of cases in which children have withheld consent to lifesaving treatment has risen, and it is now increasingly recognised that children have a right to have their views legally represented if a local authority or health authority seeks a court's leave to carry out treatment. Professionals have to consider which legal route, under either the Children Act or the Mental Health Act, is likely to be best for the individual child.

The right to be treated against her will

... My sister's inconsistent and intermittent treatment over the past eight years is largely a result of her own indecision and the inconsistencies of her abnormal mental state. The professionals who might have taken control of the situation as her health and functioning deteriorated have not done so and I must presume that they believe they cannot do so. I do not think her case is unique. There are many more people living in the community who are severely ill and are being deprived of treatment they need.

Mental health law: civil liberties and the principle of reciprocity

At a conference organised by the Law Society, Mental Health Act Commission, and Institute of Psychiatry possible reform of mental health legislation in England and Wales was discussed. It was concluded that radical legal reform was required, and that the law should be designed specifically for provision of care in both hospital and the community. Reform should be based on principle rather than pragmatism, particularly the principle of reciprocity--patients' civil liberties may not be removed for the purposes of treatment if resources for that treatment are inadequate. Protection of society from nuisance or even violence is insufficient reason for detention. Legal provision for compulsion of patients, whether in hospital or the community, must be matched by specific rights to treatment.