The Right to Refuse Treatment-Grace E. Jackson, MD

[Guest guest]

> JustSayNo

> Tue, 13 Jul 2004 19:20:33 -0400

> [sSRI-Research] The Right to Refuse

> Treatment-Grace E. Jackson, MD

>

> The Right to Refuse Treatment

>

> Grace E. Jackson, MD

> http://psychrights.org/articles/rightorefuse.htm

>

> The right of a patient to refuse treatment is based

> upon five

> constitutional protections [1]:

>

> -- the 8th amendment's protection against

> cruel and unusual punishment

> -- the 1st amendment's protection of free

> speech (freedom of thought /

> ideas)

> -- the 1st amendment's protection of freedom

> of religion

> -- the more broadly interpreted right to

> privacy

> -- the 14th amendment's protection of liberty

> (the right to be free

> from unjustified intrusions on personal security).

>

> Within medicine, these constitutional guarantees

> have generally been

> unchallenged in the case of physical (somatic)

> illness. In fact, these

> protections constitute a competent individual's

> right to accept or refuse an

> intervention, based upon the principles of patient

> autonomy and informed

> consent. Within psychiatry, however, these

> guarantees have been variably

> interpreted and restrained. First, the state has

> been permitted a range of

> activities under its police authority, in which the

> rights of the public

> have superceded the rights of the mentally ill

> [2]. Second, the state

> has been permitted a range of activities under the

> doctrine of parens

> patriae -- the 14th century theory which

> established the legitimacy of the

> state to act as guardian for those unable to care

> for themselves [3].

>

> Given the steady rise of involuntary treatment

> decisions within the United

> States (e.g, more than forty states now authorizing

> coerced outpatient

> care), and the apparent acceptance of this

> phenomenon culturally, it is

> essential that mental health professionals reexamine

> the assumptions being

> made within the legal and psychiatric communities.

>

> Assumption #1: A psychotic person who refuses

> medication (or ECT, or

> psychosurgery) does not know what he is saying.

>

> A psychotic person who experiences hallucinatory or

> delusional perceptions

> may nonetheless remain competent for the purposes of

> medical decision making

> [4,5]. This competence may very well include cogent

> objections to the use

> of biological therapies. Studies have demonstrated

> that schizophrenia, to

> name just one example, is by no means a globally

> impairing condition for

> which the ability to consent to treatment must be

> automatically questioned

> or denied.

>

> Assumption #2: An incompetent patient who declines

> medication must be

> protected by the state, with the courts ensuring the

> application of the

> psychiatric community's standard of care:

> pharmacotherapy.

>

> There is increasing evidence to demand a critical

> reexamination of the

> psychiatric community's standard of care. First,

> the record of recent FDA

> drug approvals attests to the continuing acceptance

> of egregiously flawed

> trial designs leading to the release of

> psychotropic drugs whose efficacy

> is slight, to non-existent (relative to placebo),

> and whose safety has been

> inadequately characterized [6]. Second, the same

> flaws in trial design

> continue to apply to the majority of post-marketing

> investigations leading

> to invalid assumptions about product effectiveness

> and long-term safety

> [7,8]. Third, rampant conflicts of interest now so

> undermine the integrity

> of psychiatric education, research and practice,

> that neither clinicians nor

> consumers are capable of participating in an

> objectively informed consent

> to care [9].

>

> By conceding to the authority of those psychiatric

> professionals who embrace

> a standard of care, based more upon political and

> economic considerations

> than upon objective, scientific evidence, the courts

> collude in a sham.

> That this collusion occurs out of ignorance is

> judicially embarrassing. That

> this collusion leads to the coerced use of

> chemicals with potentially

> irreversible toxicities, is shameful.

>

> If the states take seriously their charge to

> advocate for those citizens

> most in need of protection, they would do well to

> validate the claims of

> those patients - competent or not - who refuse

> treatment with biological

> therapies. Indeed, it may well be that the

> protection which patients and

> the public most need is not protection from the

> symptoms of mental

> illness, but the protection from those institutions

> which have not done

> enough to advocate for access to treatments which

> are safest, most

> effective, and most humane.

>

>

> References

>

> 1 Buchwald, William, Lazorishak, JD: The Right Of

> Patients In Mental

> Hospitals To Refuse Drug Treatment. Health Matrix

> 1986: Vol IV, No 1: 3-18.

>

> 2 Ibid.

>

> 3 Payton, Sallyanne: The Concept of the Person in

> the Parens Patriae

> Jurisdiction Over Previously Competent Persons. The

> Journal of Medicine and Philosophy 1992; 17:605-45.

>

> 4 Palmer, BW, Heaton RK, Paulsen JS, Kuck J, Braff

> D, et. al.: Is it

> Possible to be Schizophrenic Yet

> Neuropsychologically Normal? Neuropsychology 1997:

> Jul 11(3):437-46.

>

> 5 Moser, DJ, Schultz, SK, Arndt S, Benjamin ML,

> Fleming FW, Brems

> CS, et. al. Capacity to Provide Informed Consent

> for Participation in Schizophrenia and HIV Research.

> American Journal of Psychiatry 2002; Jul 159 (7):

> 1201-7.

>

> 6 Halpern, Scott D, Karlawish, Jason HT, Berline,

> Jesse A: The

> Continuing Unethical Conduct of Underpowered

> Clinical Trials. JAMA 2002: Jul 17, Vol 288, No

> 3:358-62.

>

> 7 Carpenter, William T. How the Doctor Can Counter

> Commercial Bias

> in the Dissemination of Pharmacotherapeutic

> Knowledge. The Journal of Nervous and Mental

> Disease 2002: Vol 190, No. 9: 593-596.

>

> 8 Safer, Daniel J. Design and Reporting

> Modifications in

> Industry-Sponsored Comparative Psychopharmacology

> Trials. The Journal of Nervous and Mental Disease

> 2002: Vol. 190, No. 9: 583-592.

>

> 9 Bodenheimer, Thomas. Uneasy Alliance. New

> England Journal of

> Medicine 2000: May 18, Vol. 342, No. 20: 1539-44.

>

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