Moral dilemma touching welfare of mentally ill: Killings and suicides by patients leave a question mark over the professionals

THE reluctance of some psychiatrists to detain patients in hospital compulsorily, could be one reason for the number of killings and suicides by discharged psychiatric patients.

Dr William Boyd, director of the confidential inquiry into homicides and suicides, said the decision-making of professionals had to be examined when analysing why the killings and deaths had occurred. 'There are many consultants who would do anything other than detain patients,' he said.

When asked why, Dr Boyd said: 'It's a very difficult and personal decision to decide to take away someone's liberty. Some psychiatrists are very reluctant to do it. They feel it would ruin their professional and therapeutic relationships. In other cases some members of the family are begging for the patient to be admitted while others beg for him not to be admitted. In some cases the psychiatrist gets it wrong.

'They have assumed they can only detain a patient if they are dangerous or likely to harm themselves. They don't realise they can detain a patient if his or her own health is at risk.

'The moral dilemma . . . is not often talked about. But I suspect it is a crucial feature which must be addressed when analysing why homicides and suicides occur.'

The dilemma over compulsory detention for the mentally ill was spelt out by a consultant psychiatrist in the front line of the Government's care in the community policy. Dr Graham Thorneycroft, spokesman on community care for the Maudsley psychiatric hospital in south-east London, said: 'In everyday clinical processes there are a number of tightropes you have to walk. The first is between the extent that you take away civil liberties from the patients you are concerned with against the duty of care owed to the patients themselves, and whether it is reasonable to admit someone to hospital or treat them in the community, for example under extended leave.

'The second dilemma is the extent to which you may exercise your powers to take away civil liberties against the proper concerns for public safety.

'You have to decide how you can make a reasonable judgement about the degree of risk for a particular patient in a particular circumstance, especially for people who have committed an offence or were involved in an incident, or if there is concern about the likely danger to others. One of the best predictors of violence is if the patient has been violent in the past.'

Dr Thorneycroft said further problems had been created by the new measures announced by the Government on Thursday for supervised discharge orders for patients who have been compulsorily detained under the 1983 Mental Health Act. Under the orders a named person will be responsible for each patient and failure to co- operate with the agreed treatment will trigger an urgent review of the case and possible readmission to hospital.

'What do you do if the patient says 'I'm not ill. I never have been. I want nothing to do with you in future'? Say the patient has a history of violence. Patients with paranoid schizophrenia are likely to need ongoing supervision. What degree of compulsion do you use?

'One of the keys to get quality community care is the strength of the therapeutic relationship between the clinician - who can be a doctor, a nurse or social worker - and the patient.

'If there is an element of duress or enforcement . . .the patient may fail to attend appointments or hold back information about delusions or hallucinations that may be a trigger to violent behaviour. The department's announcement does not appear to address these key questions.'