Restrictions on certain forms of treatment

British mental health legislation subjects certain treatments to special restrictions. The administration of drugs for mental disorder after the expiry of 3 months from the first administration (in the particular period of detention) requires the consent of the patient. This consent must be a real one, and there must be confirmation of the patient's understanding of the nature and effect of the treatment. If the patient does not consent, or if he or she is incapable of consenting, then there must be confirmation from an independent medical source that the drug regimen is necessary for the alleviation of the condition or for the prevention of the patient's deterioration. The doctor giving this opinion must have consulted with two other persons who have had a professional involvement in the patient's care, including a nurse but not including another doctor. The aim of this legal requirement is apparent on the face of it: the decision to follow a long-term regimen of drug therapy against the patient's will cannot be the sole decision of those responsible for the medical treatment of the patient.

Electroconvulsive therapy is subjected to the same restrictions. It may be administered with the consent of the patient, but if the patient does not consent, or is incapable of giving consent, a second medical opinion of the sort described above is required.

More demanding legal obstacles confront the use of certain hazardous, irreversible, or controversial treatments. These treatments are psychosurgery and certain hormone implantations designed to have an effect on the male libido. Psychosurgery, which involves the selective destruction of brain tissue, has a particularly controversial reputation, largely as a result of its over-enthusiastic and inappropriate use in some quarters in an earlier age when the rights of psychiatric patients were ill-protected.(21) The crudity of earlier surgery has been replaced by more refined techniques, and although there are few centres which perform it, this form of treatment of certain recalcitrant conditions has its exponents. (22>

The statutory regimen for psychosurgery in the United Kingdom is extremely restrictive. Under the 1983 Act an independent medical practitioner is required to confirm that the patient understands the procedure and its effects and has consented to it. This practitioner is also required to state that the treatment is justified as a means of preventing a deterioration in the patient's condition or promoting its alleviation. It is clear, therefore, that psychosurgery cannot be offered in those cases where the patient is incapable of giving full consent to it, thereby effectively denying it to a class of patients who might be considered for it.

Controversy over hormonal implants focuses on the issue of whether the patient in such cases can give a valid consent in circumstances in which an element of coercion may be involved. If the patient is serving a prison sentence or is facing conviction for a sexual offence, a question may be raised as to whether the treatment is wanted in itself or is merely seen as the least unattractive of two options. Again this raises the issue of paternalism: is it right to exclude a right to choose in such circumstances, even if the choice is not entirely free? In British litigation on this matter, (23) it was ruled that an injection of a hormone analogue was not covered by the Act and was therefore permissible. The recipient of the injection in this case appealed against the veto of such treatment, which he was seeking to help him avoid further sexual assaults on children.

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