Mental health care is unique in medicine in that it is an area where fully conscious adult patients of normal intelligence can be treated against their will. Furthermore, the legitimacy of such treatment turns on an essential, albeit contested, aspect of mental illness. It is of the very nature of some mental illnesses that sufferers should be treated despite their objections. (That, of course, is to put the case from the perspective of an opponent of anti-psychiatry. According to a follower of Szasz (see session 2) matters look very different. Because there is no such thing as mental illness – that is when construed as both a deviation from evaluative norms but also medically treatable – then there is no excuse for the detention and treatment of supposed sufferers (sufferers at worst of moral or other life problems). The debate about the reality of mental illness thus impacts directly on the ethical issue of compulsory treatment.)
But if mental illness does exist (as most people surely think) can it justify coercion and if so how and why?
Paul Chodoff, a professor of psychiatry and prolific author on psychiatric ethics, writing in 1984 sets out the conflict of views on this central aspect of mental health care as follows:
I have… noted… that (as happens whenever differing opinions are held with emotional intensity) a complex matter has become polarized into blacks and whites.
On the one hand there are those who regret the necessity for involuntary hospitalization but regard it as an essential last resort enabling the care and treatment of a small proportion of patients whose severe mental illnesses substantially interfere with their capacity to accept such treatment voluntarily. This is the medical model approach and I count myself among its adherents along with, I believe, a majority of psychiatrists and some lawyers as well. The contrary position is maintained in varying degrees by a smaller articulate segment of the psychiatric profession and by a number of lawyers… This is the civil liberties approach. Those who hold it have in common the conviction that the psychiatric hospitalization of a person against his or her will is a dangerous assault on individual freedom. The members of this group, however, are by no means monolithic in the intensity with which they oppose involuntary hospitalization. Some of them support Szaszian absolutism. They regard forced hospitalization of anyone for the sake of his mental health as anathema; there are no circumstances under which it can be justified.
Another and currently more influential civil liberties position is to accept forced hospitalization under certain circumstances but only in the most gingerly fashion and when hedged about with rigid restrictions. [Chodoff 1984: 384]
Chodoff’s summary reflects in part the more general rise of the civil liberties movement and the increasing stress on autonomy in medicine. That emphasis has grown with the rise of the view as patient as consumer, especially with growing awareness of the costs of medical care and the issue of who ultimately pays those costs. Nevertheless, it is neither a recent nor a local phenomenon. So what should we make of the conflicting intuitions? Is there space for a balanced view?
Reading
Chodoff, P. (1984) ‘Involunatry hospitalisation of the mentally ill as a moral issue’ American Journal of Psychiatry 141: 384-9