treatment, is impaired; the cause of this is clearly sometimes physical, but it is a
matter of dispute whether it is always physical. Sometimes #not always) this is so
serious as to amount to a really radical impairment. If this is the case, although the
impairment may sometimes be harmless in practice and leave the person with
bizarre ideas but no problems in living, it may also happen that the impaired
judgement is likely to lead to self-neglect, self-harm or violence to others. And
when this happens, considerations of the welfare of either the person themselves
or of others require that there be intervention, with or without consent. Autonomy
is not violated by this, since the interference with mental functioning makes the
person already non-autonomous.
So one may object to Szasz that, given a serious look at the empirical evidence
from words and behaviour, there are people who lack the competence to decide
whether or not they should receive medical treatment and who in the absence of
treatment are likely to do either themselves or others harm, whether by neglect or
by active violence. However, by no means all the mentally ill' are in this category, and perhaps only a small minority. Not all mental illnesses, as normally defined, affect a person's judgement #some, for example, only make them unhappy), and even those that do may not affect it in any radical way. So there will always be a problem of deciding whether the use of compulsion is right in any particular instance; and it is important to remember that in the past compulsion at all levels ± hospitalisation, treatment and restraint ± has been very much misused and over- used, and great harm has sometimes resulted. Nevertheless, great harm also sometimes resulted from failures to intervene when necessary. The decision to use compulsion thus has to be made as best one can; and as Chapter 9A shows, sometimes it falls on the nurse. The nurse has to decide the facts: whether the patient is competent and whether they are potentially dangerous. Ethically, as much as legally, the crucial things are, first, to make the decision on these criteria and not on any others #such as administrative convenience or a wish to punish), and secondly to decide thefacts'
using the considerations laid down by the law as appropriate, avoiding general-
izations that even if true may not apply to the individuals.
9.13 Ethics and forms of treatment
One problem remains. The law sets no limit on what treatments may be used,
provided there is a reasonable chance of success; ethically, too, a treatment
unlikely to succeed and unpleasant or invasive in nature is obviously to be
avoided. But ethical objections have been raised to various treatments of mental
illness even if they succeed, partially or entirely. Physical treatments, behaviourist
techniques and some forms of psychotherapy have all been objected to. Is there
any basis for these objections?
We begin with the physical treatments ± psychosurgery, ECT and drugs.
Psychosurgery is now little used, if at all, and ECT, once used fairly
indiscriminately, seems to be largely confined in its use to patients with conditions
such as serious endogenous depression, where it can be of help and even perhaps
prevent suicide. The use of drugs has, on the other hand, greatly increased, and
188 NursingLawandEthics