People with mental-health problems may in the future be allowed to make more decisions for themselves
Consider the A&E (emergency room) doctor’s dilemma. Someone suffering from severe depression is brought to hospital, having made a serious suicide attempt. Without treatment, they will die. However, they insist they want only palliative care and will regard any attempt to prevent their death as assault.
There’s not much time to make a decision. And there are two conflicting pieces of legislation to confuse the issue. In the UK the Mental Health Act says intervention is required where a mentally ill individual is a danger to themselves (or to the public). However, the Mental Capacity Act (2007) is organized around a very different legal principle: It says that if someone passes a legal test of their capacity to make a decision, then they cannot be treated without their consent -- even if they suffer from a major mental disorder.
This is not a theoretical scenario -- it happens. So do various others involving mental-health conditions -- anorexia is one, schizophrenia another — that potentially have life or death consequences.
Philosophers are now being asked to help medical and social care professionals to think through the collisions between these different approaches.
This has been prompted because a range of factors are making the need for careful thinking around the issue of autonomy more pressing: The neuroscience that helps us to understand the way decision-making processes happen in the brain is advancing rapidly. Psychiatry as a clinical discipline now operates in a legal environment increasingly shaped by human rights legislation. And decisions regarding the treatment of the mentally ill are regularly contested in the courts.
BREAKER
“Our aim is to develop a conception of autonomy that is philosophically defensible and can be applied in practice,” said Wayne Martin, a philosophy professor at Essex University who is now leading the Essex Autonomy project, funded by the Arts and Humanities Research Council.
“My initial involvement came about when I was approached by psychiatrists at the Maudsley Institute of Psychiatry [in London] who were working on the assessment of mental capacity in the lead-up to the Mental Capacity Act taking effect. They wanted to figure out what it is like for the person actually making a decision. But they also needed a methodology for answering that kind of question,” he said.
“The Mental Health Act essentially says ‘We want to protect the public from mad people,’” he said.
“That test is a public safety test; if you’re a danger to yourself or to others, then the state has a responsibility to minimize the threat to public health. In the old days, that probably meant locking you up; now, it could mean that you are forced to take your medication. Safeguards have been introduced. But the key thing is that there is nothing in that Act that talks about your freedom to make decisions for yourself. It’s all about ‘are you a danger?’” he said.
The Mental Capacity Act, by contrast, codifies ideals that have gradually been emerging in case law, he said.
“These ideals invoke the very grand principle that a person has the absolute right to refuse medical treatment as long as they have the mental capacity to make that decision. So then the question is, how do you decide whether they have that capacity?” he said.
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