Vincent Van Gogh. Self Portrait with Bandaged Ear, 1889. London, Courtauld Institute Gallery.
This month the Mental Health Act (MHA) 2007 came into force in England and Wales. This Act, which amends the MHA 1983, is just the latest in a series of Acts of Parliament that form part of an on-going search for the fine balance between personal liberty and public safety.
http://www.dh.gov.uk/en/Healthcare/NationalServiceFrameworks/Mentalhealth/DH_078743
The language used in these various Acts, both in their naming and in the way in which the illnesses and disorders suffered by those falling within their remit are described and defined, is interesting. The Lunacy Act 1890 talks of “lunatics, idiots and persons of unsound mind”. The Mental Deficiency Act 1913 introduced safeguards to monitor what went on in what were then termed asylums. In 1959, with the introduction of the first incarnation of the Mental Health Act, we see perhaps the first, modest, attempt to move away from the use of language that appears to blame and diminish those affected by the Act.
It wasn’t however until the MHA 1983 that it was explicitly stated that a person could not be deemed to be suffering from a mental disorder “by reason only of promiscuity or other immoral conduct, sexual deviancy or dependence on alcohol or drugs”. To a modern Western audience this statement, written just 25 years ago, may sound rather quaint, obvious even, coming as it did so long after the liberalisation of our society. The MHA 2007 statement that those with learning disorders cannot, simply by reason of their learning disability, be deemed to be suffering from a mental disorder seems likewise equally overdue.
What any of us might, from our own particular historical and cultural perspectives, believe we read into the language and the provisions of past mental health legislation, contemplation of this language should at least give us an incentive to ponder how our own legislative approach, and the language we use, will be interpreted in the future. We won’t, of course, have to wait long. Indeed the language, the provisions, and indeed the very existence of an Act of Parliament directed at this particular sub section of the population remains highly contentious.
The objections raised are many and varied but perhaps one of the most pressing questions raised by mental health legislation is this: what is the moral justification for upholding the right of a competent person with a physical illness to refuse medical treatment whilst at the same time make legal provisions to enable the treatment without consent of a competent person with a mental illness. The idea that someone can be both competent and subject to the MHA might surprise non-medics who often assume that in order to be considered unwell enough to be detained under the MHA the patient will, necessarily, lack the competence to act in their own best interests. This isn’t however true, with anecdotal evidence suggesting that as many as a third of those sectioned under the MHA are competent to make decisions about treatment for their mental health disorder.
A competent person with a physical illness may of course make a choice to refuse treatment. This choice may appears, to others, to be unwise or self-harming. This choice will be respected. If, however, a competent person with a mental illness makes a similar choice, and if someone in a position of authority- a doctor, mental health professional, policeman etc- notices, their choice may, under certain circumstances be overridden.
The driving force behind the well established distinction in Western medicine between physical and mental illnesses has a long and controversial history of its own. Michel Foucault argued that psychiatry and its practitioners are- unwittingly or otherwise- agents of the State providing an important mechanism of control by the State of challenging citizens. By medicalising the nature of these challenges, he argued, the State makes the deprivation of liberty of these citizens less morally unpalatable.
This theme- of using psychiatric labels to control rather than help- is taken up by Phil Barker and Poppy Buchanan-Barker in the December 2008 issue of Medical Humanities. Writing from the perspective of psychiatric nurses they argue that the use of the term mental illness facilitates control at the expense of support and care. Moreover they argue that far from acting as independent patient advocates, academic leaders in psychiatric nursing have become increasingly intoxicated by the allure of academic achievement and have lost sight of the extent to which they contribute to the State’s control of those deemed to be suffering from mental disorders.
Part of the solution they argue for involves a deliberate move away from the distinction between disorders of the mind and physical disorders, and indeed away from the distinction between those who face small challenges and those facing larger challenges in their day to day lives. In the world they argue for the role of society would be to find ways to help those facing challenges in living, whatever their origin, to face them. And, importantly, to find the courage to care about these people even if they evoke fear or appear topose some sort of threat.
This might seem like a tall order. An ideal that is difficult to live up to. And yet, over the last 50 years apparently difficult to accommodate exceptions, in terms of whom the MHA applies to, have been made. Alcoholics you drink themselves to death and along the way often cause untold harm to families and friends cannot, along with drug addicts, be deemed to be suffering from a mental disorder simply because of this behaviour. People with learning disorders are likewise protected.
I don’t know how the MHA 2007 will be reinterpreted by the next generation of legislators, whether they’ll amend it or scrap it all together. I do know that we need to start asking difficult questions now because those facing difficulties in living can’t afford to wait for the luxury of the hindsight.
Medical Humanities