Challenges to the orthodoxy

Two comparatively recent developments in health care ethics and policy further challenge the conventional bases for involuntary treatment in mental health care. First has been the shift in general medicine over the past 50 years from ‘paternalism’ and large medical discretion to patient ‘autonomy’. Interventions require ‘informed consent’; treatment without a patient’s consent can only occur if the person lacks ‘decision-making capacity’ and the treatment is judged to be in the person’s ‘best interests’. The treatment decision of a general medical patient who has decisional capacity is respected even if it appears to be unwise. This shift to respect for patient self-determination has been largely ignored in psychiatry. The second policy development is the extension in mental health care of involuntary treatment into the community, greatly increasing the scope for the exercise of compulsion. What constitutes an appropriate level of risk to justify compulsion in the community is unclear.