Ethical Issues in Mental Illness

Caroline Dunn

• Publisher: Routledge
• Year: 2016
• eBook ISBN: 9781351939072
• Topic: Philosophy
• Subtopic: Philosophy History & Theory

This book is an attempt to address the ethical issues raised by mental illness and its treatment by focusing on the question of autonomy. The mentally ill may be regarded as non-autonomous by virtue of irrationality, which may result in treatment models which deny them a voice. As a counter to this, some have moved to the other extreme and argued that the mentally ill must be regarded as fully autonomous in all circumstances, and consequently that all their wishes regarding treatment must be respected. This book examines the ethical consequences of such simplistic approaches towards autonomy and mental illness, and considers the ethical issues raised by specific forms of treatment. It is suggested in conclusion that improvement in the care and treatment of the mentally ill requires not only a fundamental change in social attitudes but also a less impoverished conception of autonomy than some of those currently employed.

1 Introduction

People have always been fascinated by the human mind and its functions and dysfunctions. Over the centuries, philosophers and scientists have suggested a variety of explanatory models for the nature of the mind and its relationship to the body; the causes of mental dysfunction have been examined and treatments for it prescribed. Today we may marvel at the explanations offered in times past for mental illness and shudder at the barbarity of the treatments inflicted upon the mentally ill. We consider ourselves to be more enlightened, both in our explanations of, and treatments for, mental illness. In the contemporary world, with ever-increasing amounts of knowledge, specialisation has entered the arena, and mental illness is now the province of a variety of ‘experts’; doctors, nurses, psychologists, psychotherapists and social workers all have their part to play in the care and treatment of the mentally ill. These experts, whose assumptions in the main often appear unchallenged and even unacknowledged within in their own fields of expertise, and in some cases, outside them, all have their corners to fight in the professional hierarchy and power stakes. All these different experts have their own models of mental illness; these may overlap and share significant characteristics, or they may diverge sharply from each other, often causing hostility and friction between their protagonists, and there may be little real understanding of these different models by professionals from the different fields whose jobs involve them in treating the mentally ill. All too often opinions polarise, the result of simplistic stances on both sides, and meaningful debate is stifled before it even begins. Thus the ethical issues involved in mental illness may be reduced to antagonistic posturing by the most vociferous members of the opposing sides in the debate; those who stand to lose most from this unseemly wrangle are the mentally ill.

Predominant amongst the experts are psychiatrists, for nowadays, the disorders of the mind are fundamentally considered to be the province of medicine. The discipline of psychiatry has sought, and some would argue, increasingly achieved, scientific exactness. Psychiatry seeks to organise the phenomena of mental illness into patterns of symptoms in order to classify different types of mental illness; applying the classification system to the experiences described by a mentally ill person then enables the ‘expert’ to diagnose what type of illness the patient is suffering from, and this in its turn indicates the appropriate treatment. Not surprisingly, such a relatively simple approach to the complexity of mental illness, resulting as it frequently does in the application of a simplistic medical model to the definition and treatment of mental illness, has its limitations; when it is coupled with an appalling catalogue of abusive practice in the treatment of the mentally ill, it is hardly surprising that a vociferous anti-psychiatry movement has developed. The term ‘anti-psychiatry’ is not used to imply any homogeneity amongst theorists who may be included under this heading, for the theoretical stances of those opposed to psychiatry are many and varied. Notwithstanding the valuable work such theorists have done in exposing the limitations of a purely medical model of mental illness, and the abuse of much mental health practice, these theories purporting to offer explanations other than medical ones for the causes of mental illness, and alternative suggestions for its treatment, are often as dogmatic and simplistic as those of the medical profession.

Mental illness involves behaviour which is often a problem to society; it often results in behaviour that is perceived by others as irrational, and consequently it poses questions relating to autonomy which have considerable implications for the treatment of the mentally ill. I have considered the general issue of autonomy and mental illness in the Chapters 2 and 3; in Chapters 3 to 6 I have considered the specific issues raised by different forms of treatment for mental illness. I suggest that there are two fundamental models of autonomy that inform treatment of the mentally ill, each of which is essentially too impoverished to deal with the complexities of mental illness; each model may result in grave injustice, even though in the best cases of its application it may be intended to do good.

In Chapter 8 I have considered community care, the aim of which was to improve the care and treatment of the mentally ill, but in a great many cases, and for a variety of reasons, it has failed them. Finally, in the Conclusion, I consider what improvements are necessary to present care systems in order to try and provide humane treatment for the mentally ill.

I have based my arguments wherever possible on the stories of those affected by mental illness; in some cases I have used written material sent to me in response to advertisements I placed asking for people’s experience of mental illness in users’ magazines such as Open Mind. I have also used material already published which gave accounts of the experiences of the mentally ill and/or their loved ones, and newspaper reports, of which there have been a significant number in the past few years, as concern mounts about the implementation of the policy of community care for the mentally ill. There are dangers in such an approach; one only has one side of the story; certainly newspaper reports often seem to have a particular slant to them; and there is always the likelihood that such material will be biased towards those who have had unhappy experiences. Nevertheless, I chose this approach because it seemed to me that in all the vast ‘expert’ literature on the subject of mental illness, the voices of the mentally ill and their loved ones were conspicuous by their absence. I can therefore claim no scientific, ‘objective’ status for any of the evidence I have used to support arguments; it was not my intention to carry out a sociological survey, however, so I do not consider this to be a problem. If nothing else, one can accord the status of ‘thought experiments’ to the cases discussed, as a valid method of exploring the issues they raise. But wherever the mentally ill and their loved ones do try and make their voices heard, there is such an overwhelming catalogue of misery reported that I do not have the slightest doubt that there is very considerable cause for concern about their treatment. If I had to sum it up in one brief sentence, I would say that the overwhelming complaint made by the mentally ill and their families is that of not being listened to or not being taken seriously.

For despite the growth of user groups, special interest groups such as MIND and SANE, the various protests made by made by those who take an ‘anti-psychiatry’ stance, and the community care movement, it is still hard to avoid the conclusion that the mentally ill do not have a voice, or, if they do, it is one that is not taken very seriously. The mentally ill appear to be largely inaudible and invisible until and unless they are perceived to pose a danger or nuisance to society. Then there appears a spate of articles in the press asking what went wrong with the system, following another tragic case concerning a mentally ill patient who has killed someone whilst in the care of the community; or perhaps the increasing numbers of mentally distressed people occupying the gutters of our cities causes concern or offence to ‘normal’ society.

I have also relied quite heavily on the two volumes of the Report of the National Enquiry into the Human Rights of People with Mental Illness carried out under the auspices of the Australian Federal Human Rights Commissioner, Brian Burdekind, and published in 1993. This report received many oral and written submissions from people affected by mental illness, their loved ones, professional carers, community organisations, members of the public and Federal, State and Territory governments. It is an up-to-date, comprehensive report; an interesting, illuminating and thought-provoking document. Although it relates to another country, I am satisfied that the nature of society in Australia is sufficiently similar to that in the United Kingdom to make the issues raised in this report equally applicable here; in the absence of any comparable British document, it has proved extremely valuable, and the British government might be well advised to consider a comparable exercise in the UK.

The issues surrounding mental illness are great, and I am acutely aware that there are many gaps in this book; I have not, for example, had the space to consider specific groups, such as the elderly, children, women or ethnic minorities, all whom could be argued to raise specific issues within the overall ethical issues which mental illness raises. All the issues that have been considered would warrant an entire book being devoted to them, not merely a chapter. And over and above all these issues there is the fundamental question of whether or not mental illness can be considered to be a valid category.

In its starkest terms, the debate about the validity of the concept of mental illness may be reduced to those who accept the term at face value and those who deny the very existence of mental illness. This issue must be acknowledged because what is termed ‘mental illness’ expresses itself in deviant behaviour which frequently causes problems to society at large. Consequently, it has been argued, most notably by Szasz, that the concept of mental illness is merely a myth, a convenient way of controlling those whose behaviour and beliefs pose a threat to the established social order. Szasz considers that the term ‘illness’ relates only to physical conditions, and that physical illness can be approached in a value-free, scientific manner; whereas ‘mental illness’ relates to behaviour, and because ‘human behaviour is fundamentally moral behaviour’ (Szasz, 1972, p. 27) conditions considered to be mental illness are really moral issues.

This then begs such questions a what is meant by ‘illness’ and how is ‘mental’ to be defined? And it begs consideration of the issues raised by the mind-body debate, for classifying illnesses as either physical or mental immediately suggests that a dualist approach to the mind-body problem is being adopted; Szasz’s approach to mental illness is certainly unrelentingly dualist.

These issues, fascinating and important though they be, must remain outside the scope of this book; I have chosen to accept mental illness as a valid concept, as I believe that there are convincing arguments to support this stance, and to consider the ethical issues raised when considering the care and treatment of the mentally ill, but these issues must be acknowledged for they are fundamental questions in the consideration of the ethical issues involved in mental illness.

All illness has an ethical dimension because illness alters one’s moral status; as Sontag has pointed out, it suggests ‘judgements of a deeper kind, both moral and psychological, about the ill.’ (Sontag, 1990, p. 43) Illness may cause a paradoxical moral state, for the ill are likely to lose certain rights, but at the same time acquire others, and will be excused certain moral obligations while at the same time acquiring others. Such changes in moral status will at least partly depend upon the meaning that is ascribed to an individual’s illness.

Meaning and morality are social enterprises into which an individual is inducted and becomes a participant, thus the experiences of the ill person are greatly influenced by the meaning that is attached to illness. In earlier ages the meaning of illness frequently had an overt moral element, often being associated with evil, sin and bewitchment; contemporary sociological analysis of illness has illustrated that this moral element, although different in form is no less present, (see, for example, Parsons, 1951, 1958, 1978). Such work shows that being classified as ‘ill’ is far from being merely a straightforward, scientific medical decision, but is also a culturally determined, social state, as indeed, are attitudes to illness and health.

The ethical implications of being defined as ‘ill’ will depend upon the time and place inhabited by a given patient - that is, a given society at a particular time in its history. For the inhabitants of Butler’s Erewhon, illness was treated as a crime, crime treated as an illness. The inhabitants of Erewhon are taken to hospital and treated as if they were ill if they commit what would be regarded as a crime in the narrator’s world: fraud, arson, robbery with violence are all met with sympathetic understanding. The ‘cure’ for such behaviour may be unpleasant, and the ‘sufferer’ is expected to pursue the relevant treatment regardless of its degree of unpleasantness, but nevertheless, she is regarded as unfortunate rather than morally deficient.

The strange part of the story, however, is that though they ascribe moral defects to the effect of misfortune either in character or surroundings, they will not listen to the plea of misfortune in cases that in England meet with sympathy and commiseration only. Ill luck of any kind, or even ill treatment at the hands of others, is considered an offence against society, inasmuch as it makes people uncomfortable to hear of it. (Butler, 1987, p. 102, emphasis mine)

It is easy to dismiss this as the artistic licence of the author, but in certain forms, illness, sin and crime have had a perilously close relationship throughout most periods of Western civilisation. Butler’s perceptive comment on the discomfort caused to the Erewhonians by hearing of the misfortunes of others is particularly relevant when considering the meanings attributed to illness, for sickness that is perceived as in some way carrying a potential threat to the non-sick can cause considerable discomfort, and with such discomfort the treatment of the sick person is affected. Such threat is not limited to a direct threat to the non-sick person’s health; it can be the fear provoked by the realisation of one’s own ultimate mortality, or the feeling of ‘there, but for the grace of God, go I.’ Cancer patients tell of being avoided by friends when the nature of their sickness is disclosed; parents of handicapped children tell of attitudes which express disgust towards their children, remarks such as, ‘You should have let it die’; ‘Why are you bringing it out in public?’ ‘Spastic’ is used by some as a term of abuse. Our supposedly rational and scientific era is far from relinquishing guilt and shame as possible meanings attached to sickness. Sontag, examining the metaphors relating to AIDS, argues that:

With AIDS, … shame is linked to an imputation of guilt; … Indeed, to get AIDS is precisely to be revealed, in the majority of cases so far, as a member of a … community of pariahs. … The unsafe behaviour that produces AIDS is judged to be more than just weakness. It is indulgence, delinquency -addictions to chemicals that are illegal and to sex regarded as deviant. (Sontag, 1990, p. 24)

Perhaps we are less removed from the citizens of Erewhon than we might like to think.

Certain forms of illness have meanings whose implications are even worse; such illnesses appear to remove the sufferer from the ranks of humanity altogether, and in the process remove rights which are normally taken for granted; morality often appears to become irrelevant if the sick person is not perceived as human. Kafka’s Metamorphosis conveys this situation starkly. Gregor Samsa’s metamorphosis into a giant insect is perceived as repulsive by his family; their initial reaction to his metamorphosis is one of shock and disbelief as they struggle to come terms with what Gregor’s illness means to them; Gregor’s metamorphosis represents to the Samsa family a form of moral judgement upon them, but for what they do not know. Although Gregor retains his human feelings, his family begin a slow process of dehumanising him; dirt is allowed to accumulate in his room and it is used as a repository for any unwanted items in the apartment. His metamorphosis creates a ‘spoiled identity’ for Gregor, and he is increasingly regarded as contaminated and potentially contaminating until eventually there is no pretence at regarding him as the person he was: Gregor suffers as Donne described, centuries earlier:

As Sicknesse is the greatest misery, so the greatest misery of sicknes is solitude; when the infectiousnes of the disease deterrs them who should assist, from comming; Even the Phisician dares scarse come. Solitude is a torment, which is not threatened in hell it selfe. … When I am dead, & my body might infect, they have a remedy, they may bury me; but when I am but sick, and might infect, they have no remedy, but their absence and my solitude … it is an Outlawry, an Excommunication upon the patient, and separates him from all offices… (Donne, ed. Raspa, 1987, p. 25)

Mental illness may result in sufferers experiencing many of the injustices so graphically described in Kafka’s fictional story because mental illness is associated with the loss of rationality, which is considered to be a prerequisite for being considered fully human. Just as Gregor’s metamorphosis strips him of his humanity and denies him the moral considerations which we take to be a right, so too do the moral consequences resulting from the pejorative meanings ascribed to mental illness have great ethical implications for the mentally ill. It seems that for many people, the degree of humanity, and therefore human rights, that is attributed to anyone bears a direct relationship to her conforming to an acceptable (and by implication, non-threatening) model of a human being.

It is these issues which I propose to address in this book. I am very conscious that it is alarmingly easy to inhabit an ivory tower and offer tidy theoretical solutions to those whose profession it is to care for the mentally ill, secure in the knowledge that one will never be faced by the intractable problems that mental illness often poses in the ‘real’ world. I would therefore like to have included more views and experiences from professionals, in order to consider the issues mental illness poses for those in the difficult position of trying to provide care and treatment for the mentally ill, but response from the institutions that I approached was virtually zero, and constraints of time meant that it was not possible to approach a larger number of institutions knowing that this only might result in a better response.

Despite the omissions that are inevitable when one considers all the many ethical issues raised by mental illness, I hope that this attempt to address what I consider to be some of the fundamental ethical issues raised by mental illness will be a small step on the way to raising the most basic issue of all, the right of the mentally ill and their loved ones to have their voices heard and what they say taken seriously.

2 Mental illness and autonomy

At the outset it must be acknowledged that some of those values which should govern our treatment of the mentally ill - benevolence and humanity - do not require detailed discussion at the conceptual level, although how they should inform treatment does require consideration, and this will follow.

However, autonomy is a different case. Autonomy is a central feature of the conception of the nature of persons and a central philosophical constituent of ethical theories in post-Enlightenment Western culture, which normally involves the belief that people are autonomous beings with the ability to make their own decisions and determine their own lives. Autonomy consequently features prominently in ideas of liberty and equality; and it is a focal point for much of medical ethics, in which specific context it relates to issues of informed consent and paternalism. However, even a cursory examination of the way the notion of autonomy is used by various authors demonstrates that its definition varies considerably. As Gerald Dworkin (1988) has pointed out, autonomy is used in a variety of ways in moral and political philosophy:

It is used sometimes as an e...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• 1 Introduction
• 2 Mental illness and autonomy
• 3 Autonomy and treatment models of mental illness
• 4 Involuntary hospitalisation and treatment
• 5 Psychotropic medication
• 6 ECT and psychosurgery
• 7 Psychotherapy
• 8 Community care
• 9 Conclusion
• Appendix
• Bibliography
• Index