Coercion, Involuntary Treatment, Ethics
Probably from the very origin of the species, human beings have used force to obtain their ends. Anthropologists have conjectured that the evolutionary triumph of homo sapiens over other bipeds may owe more to our penchant for violence than to our intelligence. History seems to confirm that most organizations of human beings- from tribes and nations to churches and professions will tend to use force to achieve their ends unless someone stops them.
Unfortunately, too few people seem interested in stopping organized psychiatry's thirst for coercive power which is once again on the increase. Like most coercers, psychiatry justifies the use of force by stirring up fear of violence by others, in this case, fear of the "violent madmen." Whenever a "former mental patient" commits a seemingly irrational crime, organized psychiatry raises the flag of fear about psychiatric patients and uses it to justify forced treatment with drugs.
When a woman was pushed to her death in front of a subway train in New York City by a man who was later identified as "schizophrenic," organized psychiatry and its lobbying group, the National Alliance for the Mentally III (NAMI), jumped at the media opportunity to call for increased mental health funding ("Munoz Sets the Public," 1999). NAMI advocated a program of total coercive control, including assertive community treatment programs," "short-term involuntary inpatient commitment," and "regular monitoring for medication compliance."
Often the use of violence is further justified on the grounds of helping the subject of control. In retrospect, we think it farfetched that witches were burned not only to protect the community from heresy, but also to cleanse their souls. Someday it may seem equally strange that we locked up, poisoned, and assaulted the brains of "patients" in order to rid them of irrationality.
In modern times psychiatry has increasingly relied on biological justifications for using force. If "mental illness" is genetic and biochemical, the argument goes, the "patient" should not be treated as an autonomous being with ordinary human rights, such as freedom of speech or the right to a trial by a jury of peers.
People labeled mentally ill are commonly locked up for what they say or think rather than for what they do. But regardless of the reason for it, the incarceration is accomplished by the certification of physicians, sometimes involving commitment by a judge. Rarely if ever does involuntary psychiatric incarceration or treatment involve the kind of due process and protection afforded accused criminals.
In previous decades and centuries, the use of force by psychiatry was largely focused on how to incarcerate patients as expeditiously as possible. Once behind walls, the victims were routinely made to undergo treatment with drugs, shock, or lobotomy without further legal process. Then during the 1960s, there was a civil libertarian backlash. Attempts were made to narrow the criteria for involuntary commitment and to provide incarcerated patients with the right to refuse intrusive, brain-damaging treatments. Now, armed with the same old biological theories but with much more drug company money, psychiatry has once again begun to expand its use of force. The newest thrust is the establishment of involuntary treatment "in the community." The patient remains outside of walls, but locked up within the system of enforced drugging.
We don't need controlled clinical trials to know the dangers involved in involuntary psychiatry. The entire history of psychiatry demonstrates the tragic results of using violence in the name of doing good. Over a 300-year span, the state mental hospital system has emotionally abused, physically tortured,
sterilized, surgically lobotomized, and even killed untold numbers of involuntary inmates. To this day, involuntary patients run the constant risk of being poisoned and shocked in the name of treatment. To call for an increase in the coercive power of psychiatry is to invite further disaster.
Excerpted from "Psychiatry's Reliance on Coercion" by Peter R. Breggin, MD in Ethical Human Sciences and Services , Vol1, No. 2, 1999
"The gap between voluntary admission and detention in mental health units" Rachel Bingham MD, Journal of Medical Ethics, 2012.
- "Coercion of Voluntary Patients in an Open Hospital." Archives of General Psychiatry 10:173-181, 1964.Reprinted with a new introduction in Edwards, R.B. (ed): Psychiatry and Ethics. Prometheus Books, 1982, and in Edwards, R.B. (ed): Ethics and Psychiatry. Amherst, New York, Prometheus Books, 1997.
- Principles for the Elimination of Restraint by Peter R. Breggin, M.D. for The Joint Commission on Accreditation of Health Care Organizations
- "A biomedical programme for urban violence control in the U.S." (Peter Breggin and Ginger Ross Breggin). Changes: An International Journal of Psychology and Psychotherapy 11, No. 1 (March) :59-71, 1993.
- "Psychiatry's Reliance on Coercion." Ethical Human Sciences and Services, 1:115-118, 1999.
- "Legal Coercion" --the Scottish Recovery Network (SRN). Tuesday, 17 January 2012 In a specially commissioned article for SRN, international mental health leader with lived experience, Mary O'Hagan, critically challenges the use of legal coercion in a world where the recovery approach and human rights are accepted norms.
"Schizophrenia with preserved insight is associated with increased perfusion of the precuneus," by Catherine Faget-Agius, MD, et al. J. Psychiatry Neuroscience, April 12, 2012. This study is claimed as evidence of the biology of the denial of schizophrenia by patients-- "anosognosia." There are many negative aspects to the study to be analyzed more fully. The argument that a patient who does not accept her diagnosis of schizophrenia has a physical brain difference is a form of coercion. (GRB) This argument is used to justify involuntary treatments including forced, court-ordered injections of long acting socalled antipsychotic drugs, involuntary hospitalization, and other involuntary 'treatments.'
"Court strikes decision for mentally ill woman’s abortion--Backs rights those ruled incompetent" By Peter Schworm, Globe Staff January 17, 2012
Earlier this month, a Norfolk probate judge declared a pregnant woman with schizophrenia incompetent and ordered her to undergo an abortion, stating she could be “coaxed, bribed, or even enticed’’ into the hospital for the procedure.
Unbidden, the judge further directed that the 32-year-old woman be sterilized “to avoid this painful situation from recurring in the future.’’
Yesterday, the state’s appeals court struck down the decision in unusually harsh terms, saying the woman had clearly expressed her opposition to abortion as a Catholic.
“The personal decision whether to bear or beget a child is a right so fundamental that it must be extended to all persons, including those who are incompetent,’’ the opinion stated, citing a 1982 ruling by the state’s Supreme Judicial Court.
In sharp words, yesterday’s decision also denounced the sterilization order, a directive that several legal specialists said they had not heard of in recent memory.
“No party requested this measure, none of the attendant procedural requirements has been met, and the judge appears to have simply produced the requirement out of thin air,’’ wrote Appeals Court Judge Andrew Grainger.
The case provides a rare window into the wrenching ethical issues involved in treating pregnant women with chronic mental illness and the delicate balance between respecting their autonomy and protecting their best interests and those of an unborn child.
Specialists said the Norfolk judge, identified in the decision as Christina Harms, overstepped her bounds, and praised the higher court’s swift and unsparing reversal.
“It’s a case that stands out for protecting the rights of the mentally ill,’’ said Frank Smith, chairman of the Massachusetts Bar Association’s Individual Rights & Responsibilities Section. “The record seems clear that she did not want to have an abortion.’’ Read more here.