I admit, I fell for one of these groups on first glance. But upon further reflection and research I’ve come to the conclusion that at best, these people are well-intentioned with little grasp of logic, and at worst just plain anti-psychiatry nutjobs.
Doctors Give Medical Treatment Without Consent All the Time
Consider this, if a person comes into the ER unconscious, the doctors do whatever it takes to save that person’s life. No matter what has happened to them, or what their diagnosis might be, the doctors try to save them. The patient cannot give consent. They are unconscious. This treatment might, in fact, kill the person, but the doctors try their best even though the person is not able to give consent at that time. (There are legal exceptions to this like a do not resuscitate order, but those are the exceptions.)
The doctor does this because it’s their job to do what is in the patient’s best interest to the best of their abilities. That’s why we have doctors. We have them because these people know how to make complicated decisions that we can’t make ourselves. They went to a decade (or more) of school for just this reason.
Why Shouldn’t A Doctor Care for the Mentally Ill the Same Way?
Now consider the following, a person is brought into the ER, probably by the police, in a psychotic episode. This person might have been running around naked, or screaming into the air, or otherwise behaving erratically, and clearly unwell. This person does not have the ability to give consent to medical treatment. Their mind is currently not their own. They are a danger to themselves, and possibly others. (That is how they ended up in the ER in the first place. If they weren't a threat, they wouldn't be there.) The patient is screaming not to give them medication in between threatening the ceiling tiles.
Theoretically, the doctor has three options.
- The doctor releases the patient. The patient doesn’t want treatment, so they are released. The person though is possibly a danger to themselves or others, so the police may have to act - not good for the mentally ill person. Even if the police don’t, the person can easily do any number of horrible things before they come out of their psychotic episode. The person might die. The person might hurt someone else. Believe it or not, many doctors care about that stuff.
- The doctor can put the person in a padded room and leave them there until they come out of their psychotic state. This would likely be without their consent too, but doesn’t involve any type of “treatment” per se. But how long is reasonable to leave a person restrained or in a padded room? What are doctors supposed to do with that person? Health care workers are supposed to somehow attend to the person’s needs like for food, water, and going to the bathroom all while the person is tied to a bed, or in a cell-like room? That sounds ridiculous, impossibly difficult for health care staff, and not particularly humane.
- The doctor can treat the person. Yes, this means medication. Probably a fairly heavy antipsychotic to calm the person down so they aren’t a danger to anyone around them and to bring them out of the psychosis.
Not Medicating People Without Consent Only Sounds Like a Good Idea
See, not medicating people without consent sounds like a good idea, but in the real world, it just doesn’t work. It doesn’t work because we don’t have any better ideas. If it were simply a matter of blinking them into safe sanity I would be all for it, but so far we haven’t developed genie technology.
I agree that once a person is stabilized and can once again appreciate their situation, they can choose not to consent to further treatment. I’m not suggesting they be medicated forever. And quite frankly if the person were to never leave their house and never hurt themselves, they could be as crazy as they liked with no bother from me or anyone else. But when you show up in an ER insistent on killing yourself or threatening to stab the blue men sitting on your shoulders, something has to be done. If there was no problem you wouldn’t be in the ER in the first place.
No one likes to have anything done against their will, I get that. Me neither. But just like you might be in a horrible accident only to wake up and find your arm amputated out of medical necessity, you also might find that after losing touch with reality you might wake up to find yourself medicated. This is a bad solution, but again, I’m not hearing any better ideas. No one wanted to amputate an arm, and no one wanted to medicate the person either.
[There is this sneaky belief that doctors want to medicate their patients. That they take secret pleasure in forcing coloured tablets down a person’s throat. I don’t believe this to be true. While there’s certainly no accounting for everyone, I don’t think anyone is satisfied with that solution; it’s just that we don’t have a better one.]
So yes, it’s stupid to think that doctors shouldn’t be able to medicate you without consent. That is their job, in the case of mental illness and in the case of any illness. So the next time someone spouts off against the evil doctors prescribing evil medications I suggest you ask them what they want the doctor to do after they have a heart attack and their heart has stopped. I mean, you wouldn’t want hundreds of joules of electricity to be pumped into your chest without prior consent; that would just be inhumane.
This argument, by the way, completely glosses over all the legal ramifications of consent, which I did on purpose, as I'm not a lawyer. I will say though that medicating a person without consent isn't an easy as suggested above particularly when lawyers take an interest.
Thanks for this post. I'm a resident in a psychiatry training program. We spend a lot of time learning about issues around consent from a variety of perspective. Hospitalizing and/or treating someone without their consent is something my colleagues and I take incredibly seriously!
ReplyDeleteThank-you so much for your comment. I'm glad to hear that people are taking it seriously, as they should. (And I believe that they do.)
ReplyDelete- N
I couldn't agree more. If I was ever in such a state, I would WANT whatever can be done to be done. Even if I didn't appreciate it at the time, I would certainly appreciate it afterwards.
ReplyDeleteWhen I was working as a nurse, I have had to restrain patients (chemically and physically until the meds kicked in) and they have always been greatful afterwards.
Bec,
ReplyDeleteWhile I do think it would be terrible to be chemically or physically restrained I think people _would_ feel grateful afterwords. Many people are, in fact, grateful for their medication - not hearing voices, not having disturbing, relentless thoughts.
Thanks for your first-hand account.
- N
I agree. When I have been in a emergency situation, be it mental or otherwise I am there for help not to hurt myself or others. I didn't like it at the time, but after coming out of my psychotic episodes I was grateful for the medication and the help. Now I have the choice in my medication decision.
ReplyDeleteHi Midnight,
ReplyDeleteThat's exactly right. You were stabilized so you could make a reasonable choice.
- N
Great post. I agree with you, and loved the example of the three options. Right on!
ReplyDelete~N,
ReplyDeleteI’ve followed your blog for some time now and for several reasons one of which is a commonality in therapy utilized by my spouse and you. The other and very much important reason is your superb ability to both articulate your thoughts and present them both in writing and orally with the additional ability to rationally delve into the heart of some difficult subject matters.
This is an excellent post and presentation in my opinion although after more than a decade of blogging I can find a number of the zealots who if I directed to this post would go off the deep end after proselytizing their opposition.
Warmly,
Herb
VNSdepression.com
Just like the controversy surrounding Seroquel, we are dealing with a very, very sticky subject, that has both positives and negatives. Like you pointed out, if there was a better way to treat someone during a psychotic episode so that medication was not used, than that would be logical. However, at this point in time that remedy does not exist.
ReplyDeleteRather, what we are left with is a topic that is similar to abortion, the right to die, church and state, evolution vs. science, gun rights. Everyone has an opinion on the subject, but more times than not they forget to ask the person who is suffering. Interest groups (like Scientology, or the groups that you were talking about) see the subject in black and white, and refuse to look at all sides of the topic, because that would undermine their goal.
Thank you for posting this, as I was not privy to the medication without consent topic. Maybe one day we will stumble across a new solution that will help, but at the moment, all we can do is continue debating.
Dave.
I guess I’ll have to be the one of those who has to disagree.
ReplyDeleteYes people do get treated without their consent in emergency situations for all types of medical crisis...but in the case of mental health that easily gets extended to a lifetime of being medicated by doctors that “know” best. I’m not for a two tiered society where some Canadians are afforded the full protection of the Charter- and others (those mentally ill folks- we know who we are) are not.
I’ve broken bones and had other major surgeries…but the doctors didn’t follow me out into my daily existence or mandate that I should take powerful painkillers to treat my conditions for the rest of my life. When I requested to be taken off of pain killers– that was no problem as I had that right – because the pain of having my arm screwed together with posts was more tolerable than the side effects of morphine.
I’m surprised no one has mentioned our fabulous friend and infernal neuroleptic side effect: Akathisia. You know the good old “indescribable sense of terror and doom” dysphoric kind. I’ve talked to many doctors about that one: The reponse- take MORE medication or just wait till it wears off.
Next time any of us is treated without our consent (maybe in between the terrified pacing and reading your handy pamphlet: Urinary retention- why you can’t go pee on Haldol & other fun anti-psychotic meds) we can ask our doctor to Google “akathisia and suicide”…lots of fun studies.
And I know you didn’t go into the details of consent…but I’m a Survivor and I work in the mental health field….the system would very much like to do away with any type of express consent and just go with implied consent…so we’re all going to be screwed if we don’t stand up.
So.No.To.Doctors.Medicating.Without EXPRESS consent. We’re all equal citizens let us keep it that way. Besides I like to pee without a catheter.
Ultimately taking meds or not taking them is an individual choice…whatever improves the quality of someone’s life is important…but it has got be a free choice…I’m not a believer in force leading to healing and good relationships.
Long time reader- first time crabber. Have a good weekend all.
A
Hi Herb,
ReplyDeleteWell thank-you. Feel free to send the zealots my way, their lack of reason tickles me.
- N
Hi David,
ReplyDeleteSee, that's the thing - people refuse to look at all sides because of an _agenda_. It's much easier to be outraged than it is to think. I was trying really hard not to mention the "S" word, but now that you have, yes, Scientologists are the root of a lot of this agenda. I try really hard not to dislike any group, but any group that insists on everyone throwing their meds out the window really gets under my skin.
- N
Hi Anon,
ReplyDeleteFeel free to be the dissenting opinion, I have no problem with that.
Once you leave the hospital, no one can _make_ you take a drug. The doctor isn't there with a glass of water, a tablet and a gun. Once you get out of the hospital what you do is up to and something each individual has to take responsibility for. You stopped taking pain pills, well someone can stop taking antidepressants too.
Yes, I know this is easier said than done and yes, some doctors are aggressive in their assertions regarding medication. But seriously, would you jump off a cliff if a doctor told you jump to???
Yes, there are many disabling side-effects. You'll get no argument from me on that, just as there are side-effects to all medication. That means that some people will find them intolerable and choose to get off the meds. That's fine with me. Life's a tradeoff.
And while you've said you're against it, you haven't proposed an alternative. What would you do with the psychotic in the ER?
And while you suggest that doctors don't want to consider matters of consent at any time I see no evidence of this and do not find it to be particularly believable. Obviously some doctors are immoral but I wouldn't say that is the majority.
- N
“Once you leave the hospital, no one can _make_ you take a drug”.
ReplyDeleteI’m afraid that this is simply not true. Maybe if you’re sharp with words or can get a lawyer, have gone to lengths to read the same medical texts as you doctor, are middle class and are a native English speaker – then you can talk your way out of taking meds.
Yes on paper we have choices and even Community Treatment Order (CTO) legislation states that individuals have to consent to being on the order – but the reality of this usually ends up as coercion. Additionally the Courts can mandate you to be on depot injections. I see it all the time...and frequently it’s totally discriminatory. We look into things like the demographics…and you better believe it’s not usually white middle class kids that are forced to take meds.
Our own schemata will influence us obviously. I’ve no intention of arguing anyone to my exact point of view (even if this were possible then the world would be boring–ha). You’ve been writing from your own personal experiences…so your reflections are accurate…but there is another world, the homeless guy kicking the can on the street…I’ve been there with him- lived that life also- and I’m writing to you out of frustration for the things I have seen. And sure I’m mad as hell (not at you personally) but rather at the generally accepted level of discrimination out there. The idea that ANY of our own would just plainly state that person with mental health conditions should be treated without their consent (and no I don’t think it’s remotely similar to regular emergency medical intervention) lowers us all to a sub class of individuals. I dare anyone to take some general statements about what’s good for individuals with psychiatric disabilities and substitute any oppressed or marginalized peoples throughout history. It’s a fun game: Those _______ shouldn’t have rights…they frighten us good and decent taxpayers…they should take behavior altering medicine…heck we shouldn’t even ask them.
Even after my little rant…I’m not anti-psychiatry. Yes there are some seriously caring doctors that we’ve worked with. However when working with severely marginalized persons, homeless, trauma survivors, the criminal justice system users etc, many of the people providing services do not have a rights based or social justice perspective (and sometimes are just the leftover bottom feeders of their profession). Think about it…where do you want to work after you get your medical degree? In a nice office or down at the jail? It takes that special someone to want to provide service when everything smells like piss and people yell and scream at you (and while I don’t like getting yelled at either – god I love those guys).
Down here on the front lines there is not much access to decent anything, let alone private (caring) psychiatrists. Rather we have plenty of arrogant small minded doctors, do-nothing social workers and terrible supportive housing workers. That’s right imagine your landlord is a Mental Health agency that can call the police on you when you say you don’t want to take your medication – happens all the time. If you happen to get a lawyer and win that fight the next step is your eviction. Welcome to the shelter or the sidewalk…the choice is all yours!
continued....
A lot of my bitching comes from seeing how the system deploys its limited resources. When the multi-million dollar Assertive Community Treatment Teams were funded they had to serve someone right? Did those individuals prove to be the most difficult, volatile, seriously ill etc? Sometimes…but often the services frequently discharged those difficult individuals and opted for persons that were much easier to manage. Since just like many other regular lazy folks they like getting more money for less work.
ReplyDeleteWe’re down here working with that guy that’s seriously ill and even though it hurts me in the gut to say…sometimes we need emergency psychiatric care for our guys and it is simply not there…even in life threatening situations.
It takes a rare psychiatrist to actually be astute enough to realize that medications can have paradoxical effects (let alone the resident on call). That all those side -effects listed for atypical anti-psychotics actually can mimic the disorders they are purported to treat. That sometimes something given to someone to “calm” them can actually create a reaction that creates severe agitation or worse. Sure the doctors read about it in their textbooks…but on the day it happens…well the lights are on but no one is home.
It’s funny that mental health experience is one of those grey areas that one’s experience counts for little. In a room of shrinks who can put up there hand and say they lived through the things that they have only read about and observed…or have actually take nearly all of the drugs currently available and know what they feel like. It’s almost laughable when doctors tell someone they shouldn’t be feeling such and such. Is this not your own experience also?
Seems all they have on offer at the ER is injectable anti-psychotics. No one is force injecting people with just benzodiazepines like Valium or Ativan. Even if you asked for that it would be viewed as “drug seeking behavior” – seeing as how a lot of people like the feeling they get from these type of drugs – and not many people come running to tell me how great their new atypical anti-psychotic feels.
Yeah I admit it’s probably a bad idea all around but remember we’re taking immediate emergency treatment not ongoing treatment options – just let’s get a handle on things right for now. And forget about the addictive class that benzos are in…getting off of any psych drug is a bit like dying. I’m sure we both know that all too personally.
As far as emergency psychiatry goes I don’t really know what can be done. Yeah- no one can just do “whatever” in modern society without some repercussions...but one would hope that we’re all considered equal under the Charter. If you told the ER you couldn’t tolerate ANY neuroleptic (since you’d tried them all before) that they might actually listen to you in the same way as when you tell them you’re allergic to penicillin. After I had an allergic reaction to penicillin no one ever suggested I should take it ever again. Not so with neuroleptics. Not even with serious side effect complications...yep still told to take them over and over...like a stupid busted cuckoo clock. And I’m glad for the experience...so when some walks into my office and tells me as such I know it’s a true (albeit horrible) experience for that person.
continued...
My own view of psychiatry is rather dim due to my own experiences. A doctor saw me for 5 minutes when I was a teen and wrote: Paranoid schizophrenia. However I did not have Schizophrenia. Doctors like their records very much - so this disinformation followed me around for more than ten years - yep the wrong treatments continuously. The story has a bittersweet ending as sometimes it takes a bigger more arrogant doctor to tread over another doctor’s diagnosis. It's these types of happenings that attracted me to this work.
ReplyDeleteAs far as consent goes...I’m not talking about a doctor talking to someone face to face about treatment etc...but rather consent on a system level. Yes the electronic age is here and there are going to be electronic health records - the infrastructure is being set up right now. Yes there will be unique identifiers to your previously “aggregate” health data. If you’ve used the hospital then YES there are assessments made on you that will be shared via you “implied” consent. That means if you disagree with a health care provider and switch services then your records will show up at the new place (like those fun filled misdiagnosis’s!). The Hospitals in Ontario use record keeping that includes labeling you “aggressive” when you simply so no to medication – even a simple "thanks but no thanks" gets you the label- and its stored forever in your new shiny electronic health record.
There is so much more to tell...my brain is bursting. For example there is no clear definition of what constitutes a “health” record. That means if you played with matches and “accidentally” burned down your aunties shed in 1982 at age 10...this could find its way into your health records and be used to deny you supportive housing at age 48. Yep even if you willfully committed a crime in the past and served your sentence and was deemed rehabilitated by the criminal justice system this information could still possibly end up in your health records...its already happened plenty! Health care information custodians are not allowed to be selective about what they keep...if it shows up in the fax or other means then we have to keep it. When some well meaning worker asks you to sign a consent for information form– then they – and anyone else they’re working with (thanks to implied consent) are getting to read these things.
continued...
Also Police keep records of non criminal contact with person with mental health issues. There are no current regulations surrounding this procedure- each division and Province can do what they want with this information. Now if you had a heart attack and the police responded via a 911 call…your health information would be strictly confidential (By LAW!!!). But if a desperate mom calls the police because her daughter is locked in her room and thinks the family is against her…then this information can be released to future potential employers via a police check. Obviously the mom and daughter need help and supports...but 8 years later this information could bar the daughter from ever receiving an MSW in social work. Can you imagine if a potential employer called and requested health information from the police and they said you had a weak heart? Lawsuit city!
ReplyDeleteYes you need to have a police check to work in social services – a good thing right? But it should be your choice if you want to “out” yourself to you future employer – seeing as you have never committed a criminal offense (or is being crazy criminal?). Addictions services see the merit of hiring recovered addicts…the Mental Health system however sees little merit in hiring psych survivors to fulfill salaried positions on par with other social service providers. They much prefer us to be ghettoized as paid “peers” at minimum wage (who in the world has paid “peers”?). Some of us can be “out” but many would put their jobs in jeopardy – and I’m not taking about sigma- there will always be bigoted people in the world - but rather out and out illegal discrimination against and individual with a disability. Have fun proving anything in court like a wrongful dismissal.
So believe what you want...but be sure that it’s a two tied discriminatory society here in the great country of Canada, 2010. While these statements are written from my particular slant – let’s be clear: This information is not just hearsay or stuff someone told me, or I that read on the net…I’m right there at the table when this shit goes down.
And yes sometimes a doctor does (metaphorically) tell one to jump off a cliff. You get to read the fine print of the court order on the fall down.
A.E.
Back in the dark ages, not so long ago, here in the US of A... a person could be medicated against their consent if a loved one convinced a doc that they (the person) was crazy enough. Or, the doc just felt the person needed to be medicated. It had little to do with whether that person truly was a danger to oneself or others.
ReplyDeleteYou could even take your wife in to receive ECT or a lobotamy, if the doc felt it the right thing to do and you agreed. While wife was just going through post partum depression perhaps.
I get that if someone is brought into the ER via law enforcement and is psychotic and off their wit's end that perhaps a good shot or two would be beneficial. I've been known to walk into my ER because I did not have a pdoc and just wanted a med to help me sleep and to ease the anxiety.. would not have wanted to be "forced" on Haldol (which I have taken in the past during psych inpatient stays and so I get the inability to pee and the shuffling).
See... in giving docs the right to medicate what they deem is a mentally ill patient with psychotropic medications, or ECT, or any other form of invasive and extreme treatment in the ER would also open the gates for any psychiatrist in their private office to do so as well. At least here, in the US of A. Seems if one can do it then all wish to do it, would not want to discriminate now would we?
By the way, there are medical disorders and illnesses, when awry, that have symptoms that can quite often mimic a form of mental illness and psychotropic meds and/or ECT, etc.. is not the correct treatment. You give a doc the ability to just force meds without consent... you run that chance that they are treating someone as mentally ill when they actually had another medical disorder.
Course now, if one was brought in because he set fire to his property and the reason being that the purple men ran into the high grass and hid when he invited them to come and roast hot dogs and marshmellows with him... and he became angry cause he was being hospitable and they were being rude guests on his property so he decided to flame throw and burn them out... maybe, he needs a shot of something. Or, the one who wrapped his legs and arms around a tree trunk, stark naked, and demanded to speak to both Elvis and Jesus and then whizzed all over the back seat of the patrol car as the deputy assured him he would be taken to see Elvis and Jesus if he'd just get in the car... likely needed a little something something as well.
The mother, with 4 children, who had no money and whose husband was an alcoholic and beat the crap out of her.. who went to her primary care physician and he asked her how things were and she honestly said... so he referred her to the mental health center for counseling, and then her children were removed by DSS as soon as she showed up because he (not realizing) called DSS and asked if they could help her... so she went into major breakdown in the lobby of the MH center and was driven to the hospital... likely got given something as well but I would have hated to know it was against HER consent.
--- T
A.E.
ReplyDeleteThank-you for sharing your thoughts on this issue. Obviously you care a great deal about it.
I definitely can't respond point by point, but here are a few thoughts:
1. Yes, courts can order depot injections. That is extremely rare in the mentally ill community as a whole.
2. Undoubtedly coercion is used to get people to take medication. Nevertheless, we are adults and we (or our caregivers) are responsible for our choices.
3. I believe mental illness _is_ like other illnesses and just like other illnesses, in some cases intervention is needed. I don't believe that giving antipsychotics without consent to a person in a psychosis and in an ER is degrading whatsoever. I think it's appropriate.
4. Certainly any time a group of people receives power there are people who use it badly. No argument. That isn't an argument against power, that's an argument about appropriate use.
5. Yes, life on the street is different. The homeless have many fewer options and yes, they face many challenges.
6. Yes, the system sucks. No argument. I can't get to see a psych. Even though I've recently been very suicidal. Even though I'm having problems with meds. Even though my GP has no idea what to do. Even though _she_ thinks I should see a psych. Yes, the system sucks. Many of us get fucked with it, and people die because of it. All that fucked-up environment though, doesn't change the fundamental issue: people in crisis need to be treated, sometimes without their consent.
7.Yes, of course doctors get it wrong. When you're the zebra and not the horse, you're harder to figure out. And yes, I think it's ludicrous that I doctor would tell me I'm not feeling how I feel. I often want to stuff handfuls of pills down their throats, but that's me.
8. Two things in defense of the doctors. First, they have limited tools with which to deal with these issues. Sometimes they have nothing better to offer than that which you have tried and failed. Second, many mentally ill people don't express themselves well when talking to their doctor. There are many reasons for this, but I do believe that doctors just don't always get the message that the patient is trying to send across. This isn't either person's fault, just a fact. The mentally ill often need advocates to help them during appointments. I actually suggest this for everyone.
cont...
#2
ReplyDelete9. Yes, there are many problem with medical records. I agree completely.
What we have is a big problem with no great solutions. I can understand how frustrated and angry you are with dealing with it every day. I get that way sometimes too. I understand how unfair it is and how things need to change. Believe me, I get it.
It's great to know that a passionate person like you is out there trying to make it work for people. Just try to remember than not everyone in the mental health care system has been run over, coerced, and not all doctors are unfeeling and disrespectful. You see the exceptions all day long and you think that's all there is, but there isn't. I'm an exceptional case, and I know it. Many mentally ill people get help, find medication, have successful relationships with the doctor and move forward.
Again, thanks for your comments.
- N
T,
ReplyDeleteI'm not advocating doctors drugging patients without consent _in_general_ (I don't even know how they could). I'm talking about in emergent cases. It _is_ appropriate. When a person can't appreciate their situation they often because a danger to themselves and those around them. Medication is completely reasonable in that case, not to mention what is done right now for mental and _any_other_illness. If you're in danger, they are trying to fix you. Period.
As for forced ECT, I would consider that mostly a dark ages thing. The only way that would happen is if ordered by the court if your ability to consent had been revoked and a doctor thought that should be done. That's a lot of legal wrangling that has to be done before it's even an option, not to mention you'd have to be inpatient.
There are many protections both in the US and Canada to ensure a patient's rights outside of emergent situations. I have no doubt that some doctors abuse patient's rights, but that doesn't mean they are the majority.
This issue plays to people's fears and so they feel it should _never_ be right to give meds without consent. But that's just as ridiculous as saying you shouldn't be fibrillated without consent. If I were fibrillated I would die due to a preexisting implant, but that doesn't mean I think the doctors would be wrong for such an action in general.
- N
great post!
ReplyDeleteSuzanne - thanks!
ReplyDelete- N