Article
Guest Editorial
Whenever organized psychiatry claims to speak for the rights of others, it is perhaps time to step back and reevaluate the landscape—for altruism has had, at times, a dark heart. Community treatment orders (CTOs), controversial tools now widely adopted in various guises, have sparked a debate within (and without) the profession. Although it makes for odd bedfellows and splits between colleagues, the debate has also highlighted the arguments of those who see treatment as a right and those who see it as a choice. The case for the right to treatment has, perhaps disingenuously, been made to “force” treatment on individuals whose psychiatric illness arguably deprives them of choice. The discussion has involved the Canadian Charter of Rights and Freedoms, Section 7 of which, for example, has traditionally been interpreted as upholding an individual’s right to refuse treatment for a mental illness (1,2). The principle of self-determination has run into Gray’s “human needs perspective” that long-term institutionalization is no liberty at all (3).
The almost uniform condemnation by psychiatrists of the recent Supreme Court of Canada decision in the case of Starson vs Swayze (4) suggests that there may be a point that we, not the Court, have missed. In our zeal to treat the ill, we may set aside their wishes, however uninformed or psychotically influenced.
Each iteration of modern pharmacologic treatment is heralded as state-of-the-art and well thought-out, even as yesterday’s remedies are relegated to generic graves. With hindsight several years hence, that certainty in drug choice may seem a little awkward, as each emperor, time after time, begins to lose his clothes. From today’s perspective, refusing high dosage haloperidol injections doesn’t seem so “psychotic.”
Nevertheless, people with mental illness continue to fall between the cracks of an increasingly complicated health care system, while our duty to our patients and to society requires an assertive role in caring for those too ill to care for themselves. As social services thin, reliance on medication becomes a greater factor in ensuring adequate care. Some of the illnesses we deal with in psychiatry can imprison our patients—the keys to those prisons often taking the form of modern-day psychotropics. When these patients appear incapable of consenting to treatment (a legal determination), we use the legal determination of incapacity as a tool to turn the key in the lock. Psychiatry, we recall, is no stranger to coercive interventions—and a utilitarian model attenuates the discomfort of forced detention or treatment.
In this issue, Dr Richard O’Reilly examines the various arguments made in the debate over CTOs (5). A thoughtful advocate for CTOs and author of a Canadian Psychiatric Association position paper on the subject (6), he takes time to examine the protagonists’ philosophical differences, outlining their positions, carefully analyzing the arguments, and applying this to current practice. His view of CTOs takes into account the context, including, importantly, the limited resources available. Many questions still remain unanswered in the CTO debate.
In their well-researched paper, Dr Marvin Swartz and Dr Jeffrey Swanson look at the current state of the evidence available for CTOs (7). CTOs, mandatory outpatient treatment, or involuntary outpatient commitment (OPC) are available in various forms in many countries. Comparing outcome studies is complicated by the additional forces striving to improve medication adherence. Both authors have been at the forefront of research into OPC. Together, they conducted the first randomized controlled trial into the effectiveness of OPC and community-based care management (8). Although showing some positive outcomes, their study had limitations and showed results contrary to the New York OPC study (9). Although it remains difficult to interpret and compare studies, owing to wide variations in implementation and practice, the results offer guidance in providing care for our seriously ill patients. Unfortunately, however, the data, helpful as they may be, can be used selectively by both sides of the CTO debate. Dr Swartz and Dr Swanson resist reading more into the evidence than exists, and their review provides direction for further study.
Various principles have operated in civil commitment, including the “least restrictive alternative” (10). In fact, in the area of civil commitment, psychiatrists are perhaps most often cast as agents for state control. Moving from inpatient to outpatient committal may often appear to be a less restrictive alternative. One added feature is the implicit expectation of medication adherence to maintain outpatient status—a feature that attracts the label “coercion.” Nonetheless, there are those to whom some revolving-door patients appear to be ideally suited for this sort of intervention.Yet other alternatives exist, such as assertive community treatment teams (ACTTs). Until research demonstrates the effectiveness of CTOs over these less forceful alternatives, CTOs will require continuing justification (11). The intent of CTOs was never to supplant a well-resourced and well-funded comprehensive therapeutic community mental health system. The advent of CTOs and ACTTs may, ironically, lead us in that direction.
The evidence remains unclear, and the arguments on both sides are not without merit, but uncertainty sits uncomfortably in modern medical practice. Both sides speak to the rights of patients, and both seek the moral high ground. Thoughtful and intelligent people have weighed in, and we have initiated a genuine debate in psychiatry. CTOs may very well be an expression of both the best and the worst in current psychiatric practice. At best, we are looking at paternalism—benevolent coercion respectful of autonomy and liberty. At worst, we ignore the concerns of fairness and justice (12). Just exactly how do we balance autonomy and paternalism?
References
1. Dykeman MJ. Mental health: an evolving area of law. Mental health and patients rights in Ontario: yesterday, today and tomorrow. Toronto: Queens Printer for Ontario; 2004. p 31–3.
2. The Canadian Charter of Rights and Freedoms. The Constitution Act Schedule B 1982(1). Available: http://laws.justice.gc.ca/en/charter/
3. Gray JE, Shone MA, Little PF. Canadian mental health law and policy. Toronto: Butterworths; 2000. p 10–2.
4. Starson v Swayze, [2003] 1 S.C.R. 722.
5. O’Reilly RL. Why are community treatment orders controversial? Can J Psychiatry 2004;49:579–84.
6. O’Reilly RL, Brooks SA, Chaimowitz GA, Neilson GE, Carr PE, Zikos E, and others. Mandatory outpatient treatment. CPA Position Paper 2003–43. Ottawa: Canadian Psychiatric Association; 2003.
7. Swartz MS, Swanson JW. Involuntary outpatient commitment, community treatment orders and assisted outpatient treatment: what’s in the data? Can J Psychiatry 2004;49:585–91.
8. Swartz MS, Swanson JW, Wagner R, Burns BJ, Hiday VA, Borum R. Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry 1999;156:1968–75.
9. Steadman HJ, Gounis K, Dennis D, Hopper K, Roche B, Swartz M, and others. Assessing the New York City outpatient commitment pilot program. Psychiatr Serv 2001;52:330–6.
10. Hiday VA, Scheid-Cook TL. Outpatient commitment for “revolving door” patients: compliance and treatment. J Nerv Ment Disord 1991;179:83–8.
11. McIvor R. The community treatment order: clinical and ethical issues. Aust N Z J Psychiatry 1998;32:223–8.
12. Geller JL. Rights, wrongs, and the dilemma of coerced community treatment. Am J Psychiatry 1986;143:1259–64.
Author
Assistant Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario.