Psychiatry (Abingdon, England)最新文献

The Mental Capacity Act Deprivation of Liberty Safeguards have been introduced to provide a framework for people who are, or may become, deprived of their liberty. Here, I describe the background to the legislation and the assessment process that leads to authorisation of deprivation of liberty. I also outline the review and appeal processes and consider some of the challenges that may be associated with implementing the new legislation.

The Mental Health Act (1983) and the Mental Capacity Act (2005) (both amended by the Mental Health Act (2007)) together provide a comprehensive framework for the care and treatment of people with a mental disorder in England and Wales. The Mental Health Act relates solely to the treatment of mental disorders whilst the Mental Capacity Act has much wider applicability to decisions surrounding treatment and care where a person lacks capacity. Psychiatrists require a good working knowledge of relevant mental health and mental capacity legislation whatever jurisdiction they work in: here, key legal issues for England and Wales are briefly reviewed.

The article reviews some of the possible factors, namely the existence of special legal provisions, the facility for compulsory treatment and the role of the media and academic publications, which may contribute to the enhanced perception of risk to others from those with mental disorder and the relative neglect of mentally disordered people as victims of crime.

Despite our intuitions, there is no generally agreed definition of criminal responsibility. Here, the relevant English legal background, the mental condition defences, and the main philosophical theories of criminal responsibility are reviewed. The latter are the choice and capacity theories, character theory, agency theory, social theory, and the definitional theory. The psychiatric defences of insanity and diminished responsibility are considered in respect of each of these theories. Although criminal responsibility does not have any explicit role in English criminal law, it does pervade the system, and the problem with the lack of any generally agreed approach is perhaps most starkly exposed when the mental condition defences are contested in court.

The Mental Capacity Act 2005 provides the legal framework within which we must now make decisions for adults who lack capacity to make decisions for themselves. It lays out a statutory test of capacity. If the person lacks capacity, it requires us to make decisions in their ‘best interests’, which means that a range of relevant factors must be considered and weighed up to come to a conclusion as to what is best for the person. The framework allows for others to be consulted and the previously known views of the person themselves to be considered. It also provides protection from liability for routine acts of care or treatment, providing that it can be demonstrated that the acts are in the person's best interests. It will require a change in the way that decisions are made and documented.

The Mental Capacity Act 2005 has put the assessment of mental capacity for decision-making at the forefront of psychiatric practice. This capacity is commonly linked within philosophy to (personal) autonomy, that is, to the idea, or ideal, of self-government. However, philosophers disagree deeply about what constitutes autonomy. This contribution brings out how the competing conceptions of autonomy would play out in psychiatric practice, taking anorexia nervosa as a test case.

The question of definition of mental disorder and the related question of its boundaries have been, and remain, of crucial importance in many contexts. Two approaches were evident from the beginnings of modern psychiatry approximately 100 years ago: the medical and the psychological models, differing in several critical respects, particularly on whether or not psychiatric conditions are meaningful and understandable, and the related question of whether or not the abnormal is clearly differentiated from the normal. A third approach, the sociological, emphasized the strong connexion between so-called mental disorder and social deviance, and appeared forcefully in the 1960s as critiques of mainstream psychiatry. These controversial issues remain alive, sharpened by major changes since the 1960s, particularly the development of medications for common mental health problems and the development of care in the community for severe mental health problems.

In 2008, Community Treatment Orders (CTOs) became available under the amended Mental Health Act 2007 as a means of supervizing people with severe mental disorders in the community following involuntary hospital stays. The orders were intended to prevent relapse following discharge from hospital by requiring the patient to comply with treatment. Patients can be recalled to hospital should they not comply. The introduction of CTOs has been subject to fierce debate, which is still ongoing. This is, in part, due to a lack of convincing evidence for efficacy. The guidance from the Department of Health and from some NHS Trusts seems to favour CTOs over other means of supporting patients in the community. Early figures indicate that CTOs have already been used extensively, despite a lack of evidence to guide clinical practice. A few teething problems have been identified such as the availability of Second Opinion Appointed Doctors and the ways in which services are organized, which impacts on CTO implementation and continuity of care. Experimental research to identify for whom and in what ways CTOs may have benefits is sorely needed to aid clinical decision making.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) took effect on 3 May 2008. Here, I survey the content of the CRPD, noting that much of it will buttress existing policy initiatives. It places obligations on states (including the UK) to implement its provisions, which include standard human rights protection, rights to service provision particularly in the community, and protection from exploitation. Amendment of the Mental Health Act 1983 and Mental Capacity Act 2005 will be required to meet these standards. Although some of these changes are consistent with existing policy directions, others on their face provide a direct challenge to how we have thought about mental health law. In particular, the requirement that mental disability can never justify a deprivation of liberty (art 14) directly challenges how mental health law has been conceived in the UK. Compulsory treatment is also likely to be open to challenge, either in whole or in part. Mental health professionals must engage with these new ideas to re-formulate what mental health law is for.