DMH 18 Group of Psychiatrists
Our Ref: PL/JAJ
29th September 2004
Memorandum from Dr P Lepping, MRCPsych MSc Prof
D Menkes MD PhD FRANZCP, Dr G Harborne MB ChB MRCPsych, Dr R Poole,
Dr M Zinkler, MD MRCPsych
You have invited comments regarding the Draft Mental Health Bill 2004. Given the high quality of the Scrutiny Committee's Report on the 2002 Bill, we would like to concentrate on the changes made to the Bill between 2002 and 2004. The main change between the two proposed bills is the tightening of criteria for involuntary detention, and an increased emphasis on risk. At the same time the very broad definition of what constitutes mental illness has been maintained. In our opinion this is exactly the wrong way round and emphasises the wrong principles.
As psychiatrists we have expertise in treating those who are actually mentally ill. Sometimes involuntary detention is necessary to prevent further deterioration of health, even in the absence of a current risk to the patient or others. This useful clinical strategy amounts to secondary prevention, since further deterioration usually does confer such risk. The new Bill would force psychiatrists to wait until there is an actual risk and prevent action in patients' best interest, even when the likely course of events is painfully obvious.
On the other hand, the significant criticism about the broad definition of mental illness has not been resolved at all since the government has insisted on retaining the broad definition. In view of recent remarks by senior Police suggesting that Mental Health Services should be providing the Police information about which individuals might be dangerous, psychiatrists' ethical concerns cannot be emphasised enough over this issue. It is of deep concern that even slightly abnormal or bizarre behaviour may potentially provide grounds for involuntary detention in the absence of what we would describe as mental illness. This emphasises the stigmatisation of mental illness as something dangerous and would force psychiatrists to take on a policing role, which they not only clearly detest, but which is inappropriate, unethical and likely to prove ineffective. Furthermore, it is unethical to detain people in hospital without a clear benefit to their health. The Royal College of Psychiatrists has made clear its concerns about the threat that this would pose to the doctor-patient relationship and the patient's willingness to seek help in many situations. Furthermore, it would further damage recruitment to force psychiatrists to do use a Mental Health Act they object to on ethical grounds
In summary, the government's response to criticism of the 2002 Bill has taken us in exactly the wrong direction. Rather than changing the detention criteria they have made action in the patient's best interest more difficult by focusing entirely on risk. Ultimately this would jeopardise rather than protect patients' rights. It is disappointing that the government has not returned to the Richardson expert committee's emphasis on principles and values, which are shared by the whole mental health community.
We fully appreciate that one argument for a broadened definition of mental illness is the attempt to incorporate people who suffer from alcohol dependency. Interest groups have long lobbied the government to increase the capacity for detention when alcoholics present with suicidal ideation. However, there is no evidence to indicate that hospitalisation of individuals with alcohol dependency reduces the risk of suicide or otherwise improves treatment outcomes. Indeed, the evidence indicates that such favourable outcomes could only be achieved with well-funded Drug and Alcohol Services including effective rehabilitation options.
With regard to the changes to the Community Treatment Order, the new Bill will please neither supporters nor opponents of community treatment. This is because the provisions in the new Bill are hardly any different to the provisions of the Section 25 of the 1983 MHA. Therefore, it will not provide any of the potential benefits of community treatment whilst those opposing Community Treatment Orders on the principle that it erodes patients' rights will see the mere existence of this provision as problematic.
In conclusion, there are clear ethical concerns regarding the obvious shift from rights-based principles towards utilitarian principles in the proposed Bill. We suggest the Scrutiny Committee consider recommending the reintroduction of the clause that makes detention possible to prevent deterioration of health. At the same time one can only hope that the government will look again at its definition of mental illness and its lamentable focus on risk rather than the patient's best interest.
Dr P Lepping, MRCPsych MSc
Consultant Psychiatrist/Honorary Lecturer - N.E. Wales
Prof D Menkes MD PhD FRANZCP
Honorary Consultant Psychiatrist - N.E. Wales
Dr G Harborne MB ChB MRCPsych
Consultant Psychiatrist - N.E. Wales
Dr R Poole
Consultant Psychiatrist/Honorary Clinical Lecturer
Dr M Zinkler, MD MRCPsych
Consultant Psychiatrist - London
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