Does forced medication save lives? Questions over consent in psychiatric debate
When does the 'greater good' - the safety of the public at large and the patient - override a mentally ill person's right to refuse treatment?
It is a question asked often, and this time by the family of a Wellington man killed by a mentally ill woman who refused medication.
The days of locking up the "insane" in asylums is widely recalled as a dark blemish on New Zealand's history of mental health care.
But exactly how to treat distressed people in our communities polarises the experts.
After three months of refusing anti-psychotic drugs, the young woman assaulted her doctor when he tried to give her pills on July 1, 2015.
He sent her to Wellington Hospital in the hope she would be committed to a psychiatric ward overnight.
There, she appeared to swallow the anti-psychotic medication she had already rejected four times that day.
But within an hour of being discharged she fatally stabbed a man who had been trying to help her, and wounded four others.
No trace of the drug was found in her system, and she was later found not guilty of the man's murder by reason of insanity.
Medication can be administered involuntarily by committing a mentally ill person under the Mental Health Act.
The patient does not have to be detained - they can also receive compulsory treatment in the community.
Royal Australian and New Zealand College of Psychiatrists national committee member Dr Murray Patton says being mentally ill does not necessarily make a person dangerous.
He emphasises it is more common for mentally unwell people to be a risk to themselves than to others.
But if someone had concerns their loved one's illness presented a risk of violence, the law gave them the right to ask for a psychiatric assessment, he said.
The standard for a clinician applying for a patient to be committed was "when someone appears unable to engage in treatment and there is a risk associated with their illness," Patton said.
The clinician would need evidence there was a present threat of harm.
That grey area divides experts.
Sarah Romans, Professor of psychological medicines at the University of Otago, said if oral medication was refused, long-acting depot-medication - injected treatments - could be used instead of pills for some conditions like schizophrenia until symptoms settled.
"The nature of the illness prevents the person making an informed decision about what care they need and that's why we need to override their innate rights about refusing treatment."
A common criticism of involuntary treatment was that medication was oppressive, she noted.
"The knee-jerk reaction from so much of the community is that, 'Oh, psychiatrists are trying to inflict social control on people who have troublesome behaviour, or some criticism of the government or bureaucratic systems'."
However, Waikato University clinical psychology lecturer Dr Sarah Gordon believes compulsory treatment orders are overused in New Zealand, calling it an "abuse of human rights".
New Zealand bore higher rates of involuntary medication than other countries that had also closed their asylums, she said, adding that mentally ill people were more likely to be the victims of crime than perpetrating it.
People who were ordered to be injected with medication involuntary were also less likely to adhere to that, finding ways to evade the visits, she said. Clinicians might see rejection of medication as a symptom, whereas patients might just dislike the effects.
"It's put down to delusion or disturbed thoughts, as evidence of the symptoms of their illness. When in fact, actually, how would you react to the coercion of what these people are experiencing?"
Gordon was concerned that medication-led treatment was not focused on the well-being of the patient - but instead on those around them.
"That would include the mental health system, from my perspective. Are we medicating as a result of the burden of this person's distress on those around them?"
Mental Health Foundation acting chief executive Hugh Norriss said he advocated scrutiny of the healthcare system in the aftermath of tragedy, but he could not abide the rhetoric that often followed, demanding people be "locked up".
"These cases are tragic but I think we need to put them against the context that tens of thousands of people are going through the mental health system every year and getting good and effective treatment."
WHY IS MEDICATION REJECTED?
- According to psychiatrists, concerns about side-effects or long-term health issues is a commonly cited reason, as well as:
- Delusions of being poisoned or put under surveillance.
- A patient disbelieving they are mentally ill.
- Political views of medicine; e.g. distrust of "big pharma."
- Parents' or spouse's distrust of medication influencing a patient.