fail to remain on their medication. It is most likely that orders of the second type,
which are less objectionable, will be proposed, but this is not certain ± see part A of
this chapter.
Three objections have been made to CTOs: that they are impracticable to
operate, that they would damage the relationship between the client and the nurse
or social worker, because the latter would have to take on a policing role, and that
they would be an infringement of personal freedom. The first two objections might
well apply to orders of the first type, but do not seem to apply to orders of the
second type, in which the policing' role of the nurse would be limited to reporting the failure of the client to take their medication, and in which there would be no physically forced treatment, although the client would be compulsorily hospita- lised if they refused treatment. Would this violate a person's autonomy? When it was applied to people who would otherwise be detained compulsorily in hospital, it surely would not, since, though it would restrict them to some degree, they would be left much more free than would otherwise be the case. There is also a clear logic to this policy, when applied to the appropriate people; they require detention only if they do not take medication and therefore will not be detained as long as they do take medication. But there is one danger, that precisely because it is a mild and popularly acceptable limitation on freedom, it will be used too widely, and will be used not only to keep people out of hospital but also to restrict the freedom of people who otherwise would be left alone or would be allowed to leave hospital without further restric- tions. #There is some evidence that this has happened in Australia.) This, though, does not invalidate the use of CTOs; rather it demonstrates that, like most uses of compulsion, it is open to abuse and needs proper monitoring. In principle, though, there seems to be no valid objection on the ground of freedom or autonomy. The other proposed innovation is the provision of authority to detain people withDangerous Severe Personality Disorders' #DSPDs) in hospital. The problem
has been, as is well known, that some of the people in this category have a mental
impairment which makes them very dangerous to other people, but because it is
one for which there is at the moment no treatment they cannot be compulsorily
admitted to a hospital. The Mental Health Act has, as part of the grounds for
compulsory admission, the requirement that it is appropriate for the patient to receive medical treatment in a hospital' and the treatmentis likely to alleviate or
prevent a deterioration of his condition'. This is something that so far we have not
dealt with in either the legal or ethical parts of this chapter, because we have been
concerned with the role of the nurse which begins after the hospitalisation. But at
this point it becomes important.
There are very few people in this category, but they are very dangerous and some
of them have committed serious assaults or even murder when out of hospital. So
the motivation to plug the loophole' is very clear. Is it, though, a violation of freedom to force into institutions people who have committed no crime and whom the institutions cannot help? The answer, once again, would seem to beno',
provided the people who are `dangerous' have been correctly identified. If they
have, the protection of others is an adequate ground for detaining them in hospital
until they are no longer dangerous: indeed it would seem to be a positive duty to do
so.
MentalHealthNursing 191