A question of freedom

Most of us live our lives basically unimpeded from doing whatever it is we want to do. Despite worries about the nanny state intervening in our lives, the reality is that we consume copious amounts of food and alcohol, take drugs, have sex and overspend our money freely.

Perhaps that’s why we don’t spend a lot of time thinking about people who are not free to do those things.

More often than you might think, doctors are asked to judge who should be denied the freedom to choose how to behave.

Take this recent example. Trevor (not his real name) was a homeless man in his late 40s who used alcohol and heroin when he turned up at a hospital with a cough and shortness of breath.

He was diagnosed with tuberculosis, and given the standard regimen of drugs along with regular meals in hospital and methadone treatment. But when Trevor started feeling better, he discharged himself from care, and from that moment on he was very difficult to keep hold of.

Doctors tried to force him to stay in hospital using a public health detention order, but despite this he left about five different times.

It wasn’t until he had a near-death experience after relapsing that he decided he really needed help, and he completed his treatment as a voluntary patient mid last year.

“It should be noted that the benefits of detention were probably overestimated because, on this occasion, we were unable to do it well, it did not result in cure and there was a further period of infectiousness after Trevor had been detained on several orders,” noted Stephen Conaty, from the South Western Sydney and Sydney Local Health District public health unit.

There were good arguments to deny Trevor his freedom (by not being treated he was putting the other homeless people and injecting drug users at risk, as well as his extended family) but he wanted to be treated on his own terms.

But what happens when people’s decisions about what they want are clouded by mental illness?

This week I wrote about a terminally ill man, dubbed “J” by the courts to protect his identity, who was detained in hospital against his will in part because his wife and friends believed he was spending his life insurance payout too freely.

J spent nearly a month in hospital before successfully appealing his case in the NSW Supreme Court, which probably cost him upwards of $30,000. He died three months later.

As one letter-writer, Michele McKenzie, put it:  “Whether ‘manic’ or not, surely it is a person's right when they know they have only months to live, to spend their insurance payout in any way they wish?”

But Sascha Callaghan, a doctoral student at the Centre for Values, Ethics and the Law in Medicine at the University of Sydney, has pointed out that things any of us might do that come across as not in our best interests, out of character or just plain irritating can be seen in a whole different light when someone has a history of mental illness.

So how do you protect the rights of the mentally ill? Many legislators around Australia and globally have relied on the idea that we should only detain mentally ill people if, like Trevor, they are at risk of harming themselves or others.

There’s just one problem: there is actually no way of reliably telling who is dangerous and who is not, because harm committed by mentally ill people is incredibly rare.

Some doctors have suggested we should only be able treat people involuntarily if they lack the capacity to refuse the treatment. When I wrote about this suggestion recently, many people interpreted it as a way of making it “easier” to involuntarily treat people.

But this misunderstands the suggestion, and the motivations of most doctors. For one thing, if you are detaining people based on a basically meaningless notion of harm, then surely it is pretty “easy” to detain them if you want to.

Secondly, it brings to mind a kind of evil doctor who wants to lock up as many patients as possible, creating a mini-army of hospital friends because in the real-world no-one will hang out with him.

This couldn’t be further from the truth, with public hospital psychiatrists treating people in mental health crises often forgoing lucrative and potentially easier careers in the private system because they want to care for some of society’s most vulnerable people.

But of course there will always be the odd doctor who doesn’t have the respect for patients’ freedom that they should, and those that do can make mistakes.

And even if they have made the right call, I know from the many former patients who have made contact with me that involuntary detention can be a confidence-shattering, scary experience it is difficult to recover from.

It’s a fraught subject and one that it is difficult to know how best to deal with, particularly when, as in NSW, media scrutiny of the involuntary system is difficult and the identification of patients is banned.

One thing’s for sure: stopping someone from making choices about how to live their life is a massive decision, and too much for one doctor or treating team to make on their own.

And they don’t want to - they want to make sure there is timely and thorough oversight of their decisions to detain patients (nearly 200 of them signed a petition calling for earlier reviews of involuntarily detained patients).

And if you were J or Trevor, my bet is you would certainly want that a well.