Legal leverage

Coercion, compulsion, adherence, compliance, persuasion and like terms need to be in our clinical consciousness, as recently articulated in the editorial by Zigmond in relation to an English study on leverage. ^1,2 The suggestion that resolving the practice of leverage/coercion is best left to patient choice assumes that there is a lot of coercion going around, albeit erringly. His assumption that other branches of medicine are devoid of similar practice is flawed and incorrect. Removal of children who are obese from their parents, denial of driving rights to individuals with epilepsy who choose to drive and the mandatory revelation of HIV status to partners by reluctant spouses are but few examples of similar coercion in other branches of medicine. It is worth noting that, in these examples and in the examples of mental illness, focusing only on the patient’s choice narrows the implications of those choices as they affect others. It also takes away from physicians the collective role they play to the society at large. The following reasons are why, at the time we are trying to allow voluntary participation in treatment decisions, we must guard against amplifying and magnifying ‘choice’.

First, choice is shaped and essentially dependent on insight. Correlates of insight are no longer restricted to anosognosia-like views or neuropsychological dysfunction based on injuries to frontal, parietal or temporal lobes. Volumetric reductions in several cortical regions evinced by neuroimaging studies are well documented in chronic schizophrenia and first-episode psychosis. ^3,4 Consequently, lack of insight, unawareness of illness and the need for treatment can no longer be relegated to the domain of choice. Those involve a network of brain structures affected by the disorder. Even the law recognises this in assigning the ‘but for mental disorder’ designate in various medico-legal criteria.

Second, medico-legal provisions of treatment are unfortunately driven by public reactions to failures in the mental health system. The law is then made and takes precedence in determining the acceptable level of risk to which the society should be exposed. This is known as ‘where the public peril begins’. ⁵ In recognition of the implications of the choices made for and against treatment, the tension between autonomy and beneficence has not stopped being the most contentious of ethical quagmires. A broader perspective is in order beyond choice.

Third, the rates of coercion cannot categorically be said to be increasing, as opined by Zigmond. To modify the perceived alarming statistics he referenced, other relevant factors should be recognised alongside the increasing number of formal compulsory hospital admissions (1987–2010). The population of English society has not only increased over the past three decades, it has become more diverse with migrants who affect rates of mental disorder as well as the potential for coercion. The tolerance for mental illness and societal acceptance is changing. Community support for patients, a by-product of economic prosperity, has dwindled,⁶ contributing to coercive approaches from both family and practitioners. Although litigation of practitioners is lower in the UK than in the USA, it is nonetheless relevant in determining physicians’ attitudes towards voluntariness.^7,8

Finally, when the treatment of our patients considers the past and the future, progress in reducing stigma necessitates the use of leverage in some situations. The high rates of the use of leverage have been suggested as a good thing. The Americans have experienced a ‘before and after’ paradigm of reducing leverage. ‘Rotting with their rights on’ was not only a title of scientific publications but was the terminology used to describe the repercussions. The UK should learn from this that there are tragic and costly consequences in focusing only on choice.⁹ Despite decades of that experiment in the USA, the opinion to use leverage as a positive tool still exists.¹⁰