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Summary and Conclusions of Chapter VII

Justifying the application of coercion on a legal basis on the grounds of a psychiatric disorder is in principle a violation of the prime ethical rule of medicine, namely, that involvement and treatment may take place only at patients’ request and consent. This is partly the reason that the presence of disease and/or psychiatric disorder in itself never suffices for applying coercion. There should always also be a risk or danger caused by the disorder.

In somatic medicine the application of coercion is negligible. In psychiatry it is frequent. In these cases the asymmetrical contract relationship between psychiatrists and patients is replaced by a relationship of conflict. This change in the moral context of the relationship requires reexamination of the hermeneutical theories of explanation in psychiatry which are almost all based on contractual relations, and possibly not valid in non-contractual relations. In addition, while typologically restriction of freedom can be inferred from the presence of a psychiatric disorder, in principle it is not possible to confirm this restriction of freedom with certainty when patients experience themselves as free and deny the existence of a psychiatric disorder.

There was discussion of involuntary commitment to a psychiatric hospital as the archetypal intervention against patients’ wishes based on law. It was argued that this type of social intervention against patients’ wishes which exists several centuries already is deeply rooted in our society. Questioning its justification is difficult due to the moral implications, namely, the feeling that it would be unethical not to involuntarily treat certain people in certain situations. The opportunity for relevant feedback is almost totally absent as the situation after commitment is incomparable to that before commitment. There is an inclination to prejudice in the sense that not committing patients involuntarily is considered risky and dubious, while involuntary commitment is a safe course of action. Behavior after such a decision is generally interpreted only one way. When patients turn out to be dangerous for themselves or others, that is perceived to be proof that involuntary hospitalization was justified. When they turn out not to be dangerous, that is perceived to be due to the benefit of the change of environment and/or treatment. However, when people who were not involuntarily committed later display dangerous behavior, the involved psychiatrist is considered to have made an error of judgment.

This state of affairs facilitates deciding to involuntarily commit people. In addition, the necessity of involuntary commitment becomes like a self-fulfilling prophecy with almost no opportunity for judges and psychiatrists to learn from experience. Ethically this is inadmissible. It makes it nearly impossible to question the necessity of the procedure and the inadvisability of its abolition other than on emotional grounds.

From a medical-psychiatric point of view involuntary hospitalization is justified mainly as serving patients’ benefit. The assumption is that patients’ behaviors are affected by pervasive disorders that can improve with treatment. From a legal point of view involuntary hospitalization is justified as a form of preventive detention, for the sake of preventing danger to others or self.

It has been demonstrated by research that danger, whether to self or others, is almost not predictable. Statistically speaking, certain groups of people can be identified as being at greater risk of posing danger to others or self, but in individual cases prediction is unreliable and frequently incorrect. The inescapable conclusion is that involuntary commitment on the grounds of such prediction is unjustifiable.

This led us to the conclusion that involuntary commitment should be abolished.

In order to prepare a responsible course for abolition of involuntary commitment an interim provisional plan was designed. During this period involuntary commitment would be systematically discouraged, greatly reducing its incidence. Afterwards the remaining cases would be reviewed in an effort to achieve services that would make total abolition of involuntary commitment possible.

The conclusions reached in this chapter largely confer with Szasz’s, although they are partly based on different arguments.

Szasz posits that mental illness is a concept that can be socially damaging as it can and does lead to all sorts of legal coercion and to violation of people’s rights. His position, as far as involuntary commitment is concerned, is for the greater part supported by this book, albeit for different reasons.
However, whereas Szasz posits that psychiatric disorders are not illnesses, basing his reasoning on the value of freedom prevailing always and everywhere above the value of health, I conclude that psychiatric disorders can indeed be considered diseases. Precisely this is the reason that the prime medical-ethical rule of voluntariness in contacts between patients and psychiatrists applies. Basing justification of involuntary commitment on the concept of psychiatric disorder constitutes its improper use.
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