1.6.1 Civil Rights and Ethical Issues in Psychiatry

The Relationship Between Psychiatric Disorder and Civil Rights including Marriage, Divorce, Custody of Children and Management of Property and Affairs

Civil rights:

The relationship between psychiatric disorders and civil rights in the UK is a complex issue that has been the subject of much debate in legal and ethical circles. The psychiatric disorder can affect a person’s ability to make decisions and manage their affairs, which may have implications for their civil rights, including marriage, divorce, custody of children, and management of property and affairs.

Marriage and divorce:

The Mental Capacity Act 2005 in the UK recognizes that a person with a mental disorder may still have the capacity to marry or divorce. However, if it can be demonstrated that the individual does not have the capacity to understand the nature and implications of the decision, their capacity will be deemed as lacking. This includes understanding the obligations and duties of marriage or the consequences of divorce, as well as any potential consequences related to mental health. In such cases, the court may appoint a deputy to make decisions on their behalf.

Custody of children:

In relation to custody of children, the court will take into account the best interests of the child, including any risks posed by the mental health of the parent. The Mental Health Act 1983 provides for compulsory detention in cases where a person is deemed to be a risk to themselves or others. However, the Act does not automatically affect the rights of the person to have custody of their children. Each case is judged on its own merits and takes into account the specific circumstances of the individual and their mental health.

Management of property and affairs:

The Mental Capacity Act 2005 also provides for the appointment of a deputy or an attorney to manage the property and affairs of a person who lacks the capacity to do so themselves due to their mental disorder. The Act requires the deputy to act in the best interests of the person and to make decisions that are least restrictive of their rights and freedoms.

Overall, the relationship between psychiatric disorders and civil rights in the UK is complex and multifaceted. While mental disorder may affect a person’s capacity to make decisions and manage their affairs, the law seeks to protect their rights and ensure that they are treated fairly and equitably. The legal system takes into account the specific circumstances of each individual and seeks to balance their rights with the protection of others.

Ethical Issues Including the Use of Seclusion, Confidentiality and the Implications of the ‘Duty to Warn’

Ethical issues:

Psychiatry is a field that raises numerous ethical issues, including the use of seclusion, confidentiality, and the duty to warn. These issues have significant implications for both patients and clinicians, and it is essential to understand and address them in ethical and legal practice.

Seclusion:

The use of seclusion is a controversial issue in psychiatry, as it can be seen as a restrictive and potentially abusive practice. Seclusion is the process of isolating a patient in a room or area to prevent them from harming themselves or others, but it can be damaging to their mental health and well-being. Clinicians must balance the risks and benefits of seclusion while considering the ethical implications of this practice. The use of seclusion must be limited to situations where it is essential and must be carried out in the least restrictive manner possible.

Confidentiality:

Confidentiality is another significant ethical issue in psychiatry. The principle of confidentiality requires that information shared by patients during the course of treatment is kept confidential. However, in some situations, clinicians may need to disclose information without the patient’s consent, such as when the patient poses a risk to themselves or others. Clinicians must balance the patient’s right to privacy with the need to protect their safety and the safety of others.

Duty to warn:

The duty to warn is an ethical and legal obligation for clinicians to disclose information that may pose a risk to the safety of others. This duty requires clinicians to breach confidentiality and disclose confidential information to third parties in situations where there is a serious risk of harm. Clinicians must carefully consider the risks and benefits of disclosing information, taking into account the patient’s rights and the potential implications for their mental health and well-being.

Landmark Legal Cases

The UK has witnessed a plethora of legal cases over the years, some of which have established crucial precedents in the medical and psychiatric field. These cases have informed and shaped our understanding of seclusion, confidentiality, and the duty to warn in psychiatry. Below, we explore some of these landmark cases and their lasting implications:

1. R v Tarasoff (1976) – Duty to Warn:
   • While this case originates from the United States, its impact reverberated internationally. It stemmed from a tragic event in which a patient who confided his intent to harm a particular person ended up carrying out the act, with the victim being unaware of the threat.
   • Outcome: The ruling emphasized the psychiatrist’s “duty to warn” potential victims if a patient poses an imminent threat to them, even if this breaches patient confidentiality. The case underscored the clinician’s responsibility to balance the patient’s rights with public safety.
2. W v Egdell (1990) – Confidentiality:
   • Dr. Egdell, a consultant psychiatrist, shared the clinical notes of a patient, W, who had been detained for a violent crime, suggesting that W was still dangerous. This was disclosed without W’s consent and effectively prevented W’s release from a secure hospital.
   • Outcome: The courts ruled in favour of Dr. Egdell, suggesting that while patient confidentiality is paramount, there are instances where public interest (the safety of the public in this case) supersedes confidentiality. This set a significant precedent for confidentiality breaches in the name of public safety.
3. R (on the application of Munjaz) v Ashworth Hospital Authority (2005) – Seclusion:
   • This case concerned the seclusion policy of Ashworth Hospital, a high-security psychiatric facility, which did not adhere strictly to the Code of Practice of the Mental Health Act 1983.
   • Outcome: The House of Lords held that the hospital’s policy was lawful, as it was drafted with patient safety in mind. It illuminated the ongoing debate about patient autonomy vs. the need for safety and security in psychiatric settings.
4. R v Bournewood Community and Mental Health NHS Trust (1999) – Informal Seclusion:
   • The case revolved around the informal admission and seclusion of a man with autism and severe learning disabilities. He was not detained under the Mental Health Act but was secluded and deprived of his liberty.
   • Outcome: The European Court of Human Rights found that the patient’s rights had been violated. This case led to the introduction of the Deprivation of Liberty Safeguards (DoLS) in the Mental Capacity Act 2005, ensuring better protection for patients who lack capacity.

Legal cases serve as beacons, guiding the challenging decisions that psychiatric professionals must often make. They underscore the delicate balance between individual rights and collective safety and highlight the evolution of the broader ethical frameworks that underpin the psychiatric profession in the UK. Through these landmark cases, the boundaries of seclusion, confidentiality, and the duty to warn have been better defined, leading to enhanced patient care and clearer professional guidelines.

Overall, ethical issues in psychiatry, including the use of seclusion, confidentiality, and the duty to warn, must be addressed with sensitivity and care. Clinicians must balance the patient’s right to privacy and autonomy with their duty to protect their safety and the safety of others. The ethical principles of beneficence, non-maleficence, and autonomy must guide clinical decision-making in these challenging situations.

References:

1. Bracken, P. & Thomas, P. (2001). Postpsychiatry: a new direction for mental health. BMJ, 322(7288), 724-727. doi: 10.1136/bmj.322.7288.724
2. Harris, G.T., & Barnard, G.W. (1996). Confidentiality, the duty to warn and Tarasoff I: a review of case law. Canadian Journal of Psychiatry, 41(3), 163-168. doi: 10.1177/070674379604100304
3. Hoge, S.K., & Appelbaum, P.S. (1994). Ethics and seclusion: a quandary for psychiatry. Psychiatric Services, 45(10), 1043-1044. doi: 10.1176/ps.45.10.1043
4. Mental Capacity Act 2005 (c 9) (UK)
5. Mental Health Act 1983 (c 20) (UK)
6. Jones, R. & Elkin, L. (2015). Mental capacity and decision-making: Meeting the challenge of the Mental Capacity Act 2005. British Journal of Psychiatry, 206(6), 445-447. doi: 10.1192/bjp.bp.114.151761
7. Flynn, M., & Argyrou, V. (2017). Mental Capacity Law and Practice in England and Wales. International Journal of Law and Psychiatry, 53, 34-40. doi: 10.1016/j.ijlp.2017.07.002