treatment) for, in effect, punitive or administrative reasons, has developed. The
problem here is that it can be very difficult to determine in this area the reasons or
criteria for making any particular decision. But the ethical requirement is clear: it is
to avoid the temptation to abuse one's power and use criteria not allowed by the
law, and to follow the law strictly in making decisions.
9.12 Ethics and the current law: Szasz's view
But one still has to ask whether the law as it stands is in fact ethically ideal, or even
right. Here the most radical attack comes from those such as Thomas Szasz [1] who
believe that compulsory medical treatment, even for the mentally ill', is never justified. Even restraint, they hold, is justified only as a punishment for a crime already committed, or to prevent imminent violence, and never because a person may be dangerous' or may injure themselves or others'. Szasz's ground for this is that all those who injure themselves or others, however bizarre the circumstances, still act out of free choice and not because their mental judgement is impaired. Hence the supposedmentally ill' #who in Szasz's view are not mentally ill, but
either physically ill or not ill at all) may, like other criminals, be punished for
harming other people and they may be forcibly prevented from committing a
crime; but what they do to themselves, if they are adults, is their own business, and
they may not be restrained in advance, any more than anyone else who has
committed no crime.
Szasz has been prepared to admit that there are a few people, such as those with
advanced Alzheimer's disease, who are so incapable of making any decision that
one has to act on their behalf, as one must when a patient is unconscious. But he
maintains that the vast majority of people, including those with a brain disease or
illness #the existence of which Szasz admits) are not so mentally impaired that they
are incompetent to make decisions or are not responsible for their actions.
Although there is no obvious way of conclusively disproving this position, there is
agreat deal of empirical evidence against it.
This evidence comes partly from the behaviour of the mentally ill' and partly from what they say, either at the time of the illness or subsequently. This evidence shows, or strongly suggests, first, that there are people who suffer such distortions of perception, whether visual, auditory #e.g. hearing voices) or tactile, that they become unable to determine what is real and what is not. Secondly, there are people whose emotional state makes them unable to make any kind of serious considered judgement; this can happen, for example, in manic states which make it impossible to keep one's attention focused for more than a few seconds, or states of clinical depression in which the ability to take even a trivial decision or the sense that a decision is possible, or that it matters, can disappear. Thirdly, there are people who develop radically irrational beliefs, based on no evidence ± for example that a family member is really an imposter or an alien ± and who as a result reach radically false and irrational conclusions about what they ought to do. This is very much a layman's account, and by no means exhaustive. But I hope it serves to make the following point. Among thementally ill' are people whose
capacity to make rational judgements, even about their own condition and
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