A Philosophical Investigation Into Coercive Psychiatric Practices

MIC, University of Limerick A philosophical investigation into coercive psychiatric practices 2 Volumes Gerald Roche MSc, MPhil, BCL, BL. Volume 1 of 2 A thesis submitted to the University of Limerick for the degree of Ph.D. in Philosophy Doctoral Supervisor: Dr. Niall Keane, MIC, University of Limerick. External Examiner: Professor Joris Vandenberghe, University of Leuven, Leuven, Belgium. Internal Examiner: Dr. Stephen Thornton, MIC, University of Limerick. Submitted to the University of Limerick, February 2012. Abstract This dissertation seeks to examine the validity of the justification commonly offered for a coercive 1 psychiatric intervention, namely that the intervention was in the ‘best interests’ of the subject and/or that the subject posed a danger to others. As a first step, it was decided to analyse justifications based on ‘best interests’ [the ‘ Stage 1 ’ argument] separately from those based on dangerousness [the ‘Stage 2 ’ argument]. Justifications based on both were the focus of the ‘ Stage 3 ’ argument. Legal and philosophical analyses of coercive psychiatric interventions generally regard such interventions as embodying a benign paternalism occasioning slight, if any, ethical concern. Whilst there are some dissenting voices even at the very heart of academic and professional psychiatry, the majority of psychiatrists also appear to share such views. The aim of this dissertation is to show that such a perspective is mistaken and that such interventions raise philosophical and ethical questions of the profoundest importance. 2 The philosophical well-spring of the Stage 1 dissertation argument lay in an observation made by Philippa Foot 3 that the “ … right to be let free from unwanted interference ” is one of the most fundamental and distinctive rights of persons, a right which takes precedence over any “ … action we would dearly like to take for his sake.” This – in conjunction with the recognition that some coercive psychiatric interventions are of a gravity as to result in the personhood of the subject being severely damaged if not destroyed – suggested that the concept of personhood play a central role in the formulation of the dissertation argument. For ease of analysis it was presumed that the term ‘person’ could be defined by a set of necessary and sufficient conditions of which ‘minimum levels of rationality’ and ‘ability to communicate’ were the only conditions relevant to the formulation of justifications for coercive psychiatric interventions. This presumption was explicated into a number of postulates which enabled the construction of a rigorous foundation on which to develop the dissertation argument. This argument then sought to determine whether psychiatric assessments of irrationality were accurate and reliable. In furtherance of this analysis it was necessary to examine the reliability of psychiatric determinations in other areas of claimed expertise namely diagnosis, treatment and assessment of dangerousness. This ‘crossing of the disciplinary threshold’ brought to light the dearth of studies on psychiatric misdiagnosis and iatrogenic harm. A variant of the Precautionary Principle was developed to enable the extent of such harms to be estimated. The not insignificant levels of psychiatric misdiagnosis and iatrogenic harm and erroneous assessments of dangerousness which were thus found are of considerable relevance to any ethical analysis of the justification for coercive psychiatric intervention and serve to undermine simple paternalistic justifications. 1 The term ‘coercive’ (rather than ‘non-consensual’) is used to indicate an intervention carried out against the explicit and contemporaneous objections of the subject. 2 Not least because the number of individuals detained in Irish psychiatric hospitals is of a comparable order of magnitude to the number detained in Irish prisons subsequent to a criminal conviction. 3 See Foot (1977), p.102. ii Declaration I hereby declare that this thesis is the result of my own original research and that it does not contain the work of any other individual. All sources that have been consulted have been identified and acknowledged in the appropriate manner. ________________________ Gerry Roche iii Acknowledgements I wish to thank Dr. Niall Keane without whose help and expertise this project could not have been brought to completion. I also wish to thank Dr. Steven Thornton for his assistance at a particularly critical juncture, in the formulation of the dissertation argument. I also wish to acknowledge the assistance of Dr. John Hayes. I wish to thank Ms. Maureen Cronin BL for what much have seemed to her, endless proofreading. I wish to thank Ms. Mette Roche and Ms. Anna Wettergren for their help in translating passages from Norwegian and Swedish respectively and Mr. Charles O’Brien for translating some passages from French. I wish to acknowledge the encouragement to complete this dissertation, given to me by the late Dr. John Walsh. I wish to thank Professor Vandenberghe for the sympathetic understanding which he evinced towards a sometimes fraught and contentious subject matter; his suggestions in relation to the Conclusions were especially helpful. iv Tables of Contents Abstract ii Declaration iii Acknowledgements iv List of Tables vii List of Appendices viii Introduction 1 A: Terminological matters 3 B: The numerical frequency of coercive psychiatric interventions 5 C: Common legal and philosophical attitudes towards coercive psychiatry 7 D: Some dissenting voices from within psychiatry 14 E: ‘Crossing the threshold’ of psychiatry 20 F: Outline of the dissertation argument 23 Chapter 1 : The Stage 1 argument 38 A: Personhood: some preliminary matters. 41 B: The Stage 1 argument structure: initial outline 47 C: Unfolding the argument 48 D: Default Presumptions 56 E: The development of the revised argument in subsequent chapters 61 Chapter 2 : The psychiatric usage of the term ‘irrational’ (I): General 63 A: The Amy case 64 B: Journals, textbooks and diagnostic manuals 66 C: Conclusions 78 Chapter 3 : The psychiatric usage of the term ‘irrational’ (II): Delusion 80 A: The Blehein Case 85 B: The psychiatric definition of delusion 89 C: Problematic aspects of the psychiatric concept of delusion 95 D: Problematic aspects of the psychiatric concept of normalcy 104 E: The justifiability criterion: a philosophical ‘double standard’? 112 F: Conclusions 122 Chapter 4 : Problematic aspects of psychiatric diagnosis 126 A: The Rosenhan experiment 127 B: Some concepts relevant to a discussion of psychiatric misdiagnosis 132 C: ‘Misdiagnosis’: ambiguities and sources 155 D: Estimates of rates of psychiatric misdiagnosis 166 E: Conclusions 182 (Continued) v Tables of Contents (continued) Chapter 5 : Problematic aspects of coercive psychiatric treatments 186 A: Some ethical principles relevant to coercive treatment 189 B: Current psychiatric practice and the Section A principles: a reliance on 202 evidence-based studies? C: Current psychiatric practice and the Section A principles: treatment based solely 212 on the interests of the subject? D: Section A principles vs. Sections B and C conclusions: congruence or conflict? 226 Chapter 6 : Psychiatric assessments of dangerousness 233 A: Some earlier references to assessments of dangerousness 235 B: Mental illness as a predictor of dangerousness? 240 C: The prediction of individual dangerousness ( i.e. risk assessment) 255 D: Coercive ‘treatment’ in the interests of others 275 Chapter 7 : Coercive psychiatric interventions and damage to personhood 280 A: Non-psychiatric radical interventions 285 B: Coercive psychiatric interventions from the perspective of third party observers 295 C: Coercive psychiatric interventions from the perspective of the subject 329 D: Can a coercive psychiatric intervention be said to ‘destroy’ a subject’s 342 personhood? Conclusions : 344 A: A summary of dissertation argument 344 B: The dissertation conclusions and proposals 352 Appendices [Volume 2] 370 Bibliography [Volume 2] 511 vi List of Tables 4 [Volumes 1 and 2] Table 1-1: Indirect assessment of the reliability of psychiatric assessments of irrationality 56 Table 1-2: Possibility of determining L 2 56 Table 2-1: Analysis of more precise usages by journal type 68 Table 4-1: Journal occurrences of the term ‘psychiatric misdiagnosis.’ 167 Table 4-2: Journal occurrences of the term ‘misdiagnosis.’ 167 Table 4-3: The diagnosis of schizophrenia by three different methods 181 Table 4-4: The diagnosis of schizophrenia in relation to 42 individual Black patients. 182 Table 5-1: Reasons for prescribing antipsychotics to the elderly 221 Table 7-1: Possible effects of coercive psychiatric intervention on personhood 284 Table 7-2: Response to attempts by pseudopatients to initiate staff contact 297 Table 7-3: Public perceptions of dangerousness to others: schizophrenia vs . substance 309 abuse Tables in Appendices Table F-1: Presence of cancer compared to mammography results. 404 Table F-2: Predicting Violence with a base rate of 20%. 408 Table F-3: Predicting Violence with a base rate of 6%. 408 Table F-4: Predicting Violence with a base rate of 1%. 409 Table I-1: Frequencies of adverse events in UK hospitals 437 Table I-2: Estimates of misdiagnosis in general medicine 441 Table I-3: Estimates of iatrogenic harm in general medicine 443 Table L-1: Increased risk of stroke associated with antipsychotics use 490 Table N-1: Analysis of journal search results by category 505 Table N-2: Analysis of journal search results by precision 506 Table N-3:

Load more