Commissions, coercion and choice

The recent letter by Das ¹ was a succinct and clear appraisal of much of the Schizophrenia Commission’s report. Das takes issue with the report’s point that ‘shared decision making on medication choices is essential’, commenting that this cannot refer to ‘the patient with chronic schizophrenia who refuses all medication’ and that it is ‘obvious to any psychiatrist that the report is not referring to this type of patient’.

I do not think the issue is as cut and dried within psychiatry as Das suggests. A recent editorial in the British Journal of Psychiatry ² which proposed that patient choice should indeed be extended to patients with psychotic disorders was met with nothing but nodding heads and commendations. However, the reality of journal pages and that of NHS psychiatry is often as distinct as that of the psychiatrist and the patient with psychosis. The way decisions concerning antipsychotic medication are made is frequently quite straightforward - if you have a chronic psychotic illness and refuse treatment, coercion will be used to ensure you are receiving medication.

If two parties have diametrically opposed views and are unable to compromise, then shared decision-making will be limited. We feel ethically justified in coercive treatment because we have decided that the patient does not have the capacity to decide on their treatment and therefore we are acting in their best interests. This highlights the two issues that are at the heart of the debate: ‘capacity’ and ‘best interests’.

In practice, the judgement of capacity is often treated as a relatively simple matter, where, if a patient is refusing medication, they are seen as lacking the ability to weigh the information necessary to make this decision. The question of best interests is also frequently treated as uncomplicated, namely that it is in a patient’s best interests to ensure they receive antipsychotic medication. But can we say we know what the best interests are for a patient who has spent the majority of their life trying to avoid contact with psychiatry and has personally felt no benefit from antipsychotic medication? Are we justified in saying, as Das does, that they were ‘rescued from […] a salubrious itinerant lifestyle’? I do not think it is an impossible notion that an individual might prefer to live a withdrawn or chaotic life rather than one imposed on them externally.

Putting yourself in a patient’s shoes to determine their best interests means understanding their wishes and motivations, not those of the medical profession or the rest of society. When a psychiatrist judges the best interests of a patient, the decision is formed from within a system that is extremely risk averse and often appears to be built on the premise of avoiding psychosis to the exception of all else. The scales we use to weigh various eventualities (e.g. psychosis, stability, side-effects, risk to others) may be quite different to those that individuals would choose for themselves in their pre-morbid state. Best interests for an individual will vary tremendously depending on the attitude that person has to life. Antipsychotics can be tremendously beneficial but there will be a subset of patients who receive little benefit from them. Research on treatment trajectories ³ supports the idea that the benefit of antipsychotic medication may primarily be in ‘dramatic responders’, with patients who show a more modest response being difficult to distinguish from those treated with placebo. Furthermore, as in all of medicine, there will be patients whose long-term outcome would have been superior without treatment. Despite best intentions, our interventions may sometimes harm patients and recognising this is the only way we can make progress in minimising this unpalatable truth.

The problems we have to deal with are not easy to solve. Terms such as ‘patient choice’ are meaningless and obscure the issues at heart. We need to talk about specifics. Many of the decisions we deal with as psychiatrists are made on the basis of limited evidence and cannot be made objectively. It aids both us and our patients to realise that although psychiatric training and experience opens one’s eyes to many of the complexities of mental illness, it can just as easily narrow one’s view as to how a life can be lived.