An overdose of civil rights
David Tidmarsh
Now my knowledge of law cannot stand comparison with that of the lawyers who have been devoting themselves to the civil rights aspects of mental illness over the last few years but who, I suspect, know little of the realities of the impact of mental illness. I have now spent 20 years — and the discovery of how long it has been comes as a considerable shock — trying to help the mentally ill and their families. This time has not been spent in prestigious centres of ex- cellence but first in a large mental hospital which dealt in no small part with the human flotsam of London's West End; then in the Camberwell Reception Centre, the clientele of which includes those the hospitals no longer feel they have a duty to treat; and finally at Broadmoor from which, paradox- ically as it would seem to those who con-
sider it a closed and isolated institution, 1 have had far more widespread contact with the psychiatric services than I ever had before. My view of the Bill is therefore con- taminated by a long experience of actually being responsible for psychiatric patients and knowing what happens to those who are not receiving the treatment their ill- nesses require. I realise that this sets me apart from the academics and the lawyers who have no continuing commitment to pa- tients or their families but there may still be some who regard experience in this field as a useful basis for comment.
The content of the Bill has been much in- fluenced by MIND — or rather MIND'S American legal adviser, Mr Larry Gostin, and Mr Tony Smythe, late of the NCCL and now leaving MIND for pastures new. It would be safe to assume that these ideas were fostered within the DHSS by Mr David Ennals, formerly Secretary of State for Health and Social Services, and before that campaign director of MIND. It would be sur- prising if with this civil rights pedigree and in the present economic climate the Bill were to do much to improve the resources available for the actual treatment and care of the mentally ill, and indeed there are no such surprises. Nor does the Bill include anything which would improve the lot of the generality of patients either inside or outside hospital. The civil rights aspects of the Act will clear- ly discourage the admission and encourage the discharge of patients, but will do nothing for them thereafter. The one serious flaw of the 1959 Act was its failure to impose on local authorities the statutory duty to provide after-care facilities; this omission has thus been repeated. The coot- munity does not care unless it is paid to, and then only grudgingly. As before, relatives will be expected to shoulder mast of the burden. This point was taken up 111 the Lords by Lady Masham whose amend:, ment, designed to ensure that local authorities should provide psychiatric after- care facilities on a statutory basiS, led to the only defeat of the Government in the Lords. The Bill and the National Schizophrenia Fellowship part company over the question of mental health review tribunals. The tribunals, to which all detained patients can appeal at intervals, may order the discharge of the patient if they consider detention no longer necessary. The Bill will allow appeals to tribunals to be made twice as frequenttY as at present; it will bring in certain categories of patients who are at present ex- cluded and make it compulsory for patients to be considered by the tribunal at least once every three years. What is not ac cepted by the National Schizophrenia Fellowship is the necessity for patients de- tained for one month only to be able to al?: ply to a tribunal in the first 14 days of the!' admission. As the National Schizophrenia Fellowship put it: 'Our real problems as relatives arise because hospitals refuse 03 admit, or because compulsory powers are not taken, or because patients are discharg- ed from hospital while still very ill, with no arrangements made for after-care. The new Clause 3(A) does nothing for these Pr°:, blems. It makes the prospect of successto treatment in hospital not more likely, 1°1 less. A very sick and probably very disturb- ed person is to be badgered, in the first, critical days after admission, with talk n' appeals and tribunals. What sort of at; mosphere to encourage recovery is that,' How much confidence in his doctors and nurses will it give him?' Having sown doubts in his mind about the legality of his detention the Bill goes on to sow even more about his treatment Clause 41. This clause must have started its life as a very laudable attempt to iosertf safeguards into the administration n. hazardous and irreversible treatments such as pre-frontal leucotomy for patients whose ability to consent to treatment is imPalt.ed,,, Unfortunately this clause, as amended the House of Lords, has now been exPan'
ed to mean that the treatment of the detain- ed patient who is psychotic, disturbed and !II-sightless will become very difficult. If, as is usual in these circumstances, he is not will- ing to be treated, it will be necessary for him to be examined by a medical practitioner appointed by the new quango, the Mental Health Act Commission, a body, it must be noted, separate from the Mental Health Review Tribunal and, one assumes, with a different team of doctors.
The doctor will have to certify in writing that the patient is not capable of consenting Or, if he has not consented, that treatment should nevertheless be given. Such certifica- tion will have to be gone through for every diagnostic procedure involving physical in- terference, which must include routine haematological investigations that in other circumstances one would be sued for negligence for not doing, and possibly even X-rays. The procedure will also apply to the administration of medicines of any kind by anY route unless various emergencies specified in the Bill are imminent. Does one wait for the emergency or the doctor from
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the Mental Health Act Commission? I per- sonally cannot accurately predict which pa- tient's illness will lead to an even greater emergency and do not wait to find out which depressive will hang himself or which paranoid patient will hit someone before treating him. In this I am sure I have the support of the nursing profession as well as the National Schizophrenia Fellowship. MIND, however, would appear to disagree.
Before the Bill is passed and the treat- ment of psychiatric patients becomes once more enmeshed in legalisms, our legislators should listen to other voices from across the Atlantic who have seen the results of similar legislation and have had to coin such phrases as 'rotting with one's rights on' to describe what they have seen. I would also like to suggest that they listen most careful- ly, as I believe they have not yet done, to those in the World Health Organisation who are aware from the experience of other countries of the dangers of undermining viable systems of psychiatric care by too great an insistence on civil rights. Medic, as they used to say, tutissimus ibis.
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