The principle of the right to treatment implies that people in need of psychiatric treatment might otherwise be denied it; they might go in search of medical treatment but, because of lack of money, a shortage of services, professional incompetence or rejection by the service providers, or perhaps because of a discriminatory policy, they might fail to get the necessary psychiatric attention.
In this respect the right to psychiatric treatment is an example of the right all people are assumed to have for any kind of urgently needed medical attention. This basic human right, and its limitations, are instantly recognisable when cases of medical denial are given publicity. A homeless man might be left injured in the street because it is assumed he has no money to pay for hospital expenses and is unlikely to have any medical insurance. Or doctors might publicly debate the ethics of withdrawing expensive life-support from terminally ill patients. As with other human rights, the right to treatment is meant to support the needs of the individual when they are threatened by the exercise of social or professional expedience.
However, in respect to mental illness, it is not only the sufferers who are likely to complain about a supposed violation of the right to treatment. Complaints about violations of the right to treatment are also made by the relatives of mentally ill people. These complaints by relatives do not always arise from situations where a mentally ill person has approached a mental hospital voluntarily and been refused admission. They also arise from a situation in which the person who is said to be mentally ill denies it and refuses to volunteer for treatment.
When a person’s unusual behaviour and thinking patterns give rise to a perception that a mental illness such as schizophrenia might be the cause, and the person is unwilling to volunteer for treatment, it is common for relatives and mental health professionals to argue that the person’s refusal of treatment is a manifestation of the mental illness. That is, the presence of mental illness has clouded the person’s thinking and prevented the person from discerning for himself/herself the urgent need for treatment.
In this situation the person who is said to be mentally ill is handled as if he/she were unconscious. A person who has been seriously injured in a motor accident and rendered unconscious is assumed both to want treatment and to have a right to it. Similarly, a person who has been diagnosed with schizophrenia, and who refuses treatment, is frequently assumed to be so out of touch with reality that the ‘real’ person has been obscured by the mental illness. In this situation relatives often undertake decision-making roles on the mentally ill person’s behalf and assume that if the ‘real’ person were present he/she, like an unconscious motor accident victim, would both want treatment and have a right to it. This assumption is often made in the face of vigorous objections by the person concerned.
The ‘right to treatment’ has become deeply entrenched in the ethical consensus of the mental health system, including those on the periphery. It is argued by social workers in the United States, for instance, that the profession is required to advocate the right to treatment whenever they encounter a mentally ill person who is going untreated:
"if there are means (medications) to treat unrelieved psychosis, failure to use these means is opposed to social work principles. Similarly, failure to advocate for a patient’s right to treatment runs counter to fundamental social work principles and the right to due process. There are legal case precedents that ensure the right to treatment for people confined in public psychiatric hospitals. In the 1966 case of Rouse v. Cameron, the D.C. Circuit Court ruled that confining a person in an institution for treatment and failing to provide treatment is a violation of the due process clause of the Fourteenth Amendment."[43]
The lack of distinction in this ethical position between the advocacy of treatment for voluntary and involuntary patients brings the paradox of the right to treatment clearly into perspective. The practice of this ethical position apparently requires social workers to advocate psychiatric treatment for people who do not want to be treated. Even if the comparison of a mentally ill person to an unconscious person is acceptable, the quality and efficacy of the psychiatric treatment generally on offer also has to be considered.
In the case of an accident victim who is unconscious with serious injuries, it can be generally assumed that medical attention will more likely be beneficial to the person than detrimental. In fact, the imposition of medical treatment on an unconscious person, who has not given prior consent, imposes on the medical practitioner an expectation that the patient’s condition will not be made worse by the treatment. A patient who recovers from such a condition could be expected to show gratitude to the doctor.
However, the limitations of the analogy become clear when these criteria are applied to the post-crisis mental patient. Unlike the case of the voluntary patient related above, many former involuntary schizophrenic patients have complained that neuroleptic drug treatment did them far more harm than good. Rather than showing gratitude to the psychiatrists involved, they are inclined to argue that the coercive interpretation of their ‘right to treatment’ violated their more fundamental ‘right to refuse treatment’.
Next: Informed Consent
[43] Patricia B. Higgins, ‘Clozapine and the treatment of schizophrenia’, pp. 124–32.