What price liberty?

This is a fairly old story, but I was reminded of it by this recent post on Mental Nurse.

In July 2004, Carol Savage left an open acute psychiatric ward, where she was being involuntarily treated for schizophrenia.  She walked two miles to a railway station, where she threw herself in front of a train, and died as a result.  No-one would deny that this is a tragic situation.  Certainly Anna Savage, Carol Savage’s daughter, was greatly upset by her mother’s death.  We know this as she tried to sue the local health trust for compensation, because she (Anna Savage, the daughter) had suffered ‘distress, anxiety, vexation, bereavement, loss and damage.’  The case eventually reached the House of Lords last December, where the law lords ruled that the Mental Health Trust had violated Carol Savage’s right to life by failing to put in place restrictions which would have prevented her from killing herself.

The inevitable consequence of this ruling will be to make the Mental Health system even more risk-averse than it already is.  Health authorities, terrified at the prospect of watching their already tiny MH budgets eaten up by compensation claims, will put in place systems that recommend the most restrictive treatment and detention policies for all patients.  They’ll have to. Under the terms of the HoL decision, anything other than full-scale incarceration of a mental patient presenting a risk of suicide is a ‘violation’ of that person’s right to life.

Whatever Anna Savage’s motives in bringing the case (and, given that she was seeking compensation, it would seem that they were at least, in part, mercenary), the HoL ruling she has triggered would, if the local health board had acted in accordance with it, have had the effect of making her mother’s life more miserable than it already was.  They would have had no option but to confine her to a locked ward, where, I would suggest, her ‘distress, anxiety, vexation’ would at least have matched her daughter’s.  (Of course, unlike her daughter, Carol Savage would not have had the option of seeking comfort in the form of ‘free money’ from a desperately under-resourced health system.)  It’s genuinely very sad that Carol Savage died, but there’s one small positive thing for her – at least she’s spared the draconian restrictions that are going to be piled on top of the poor people currently suffering through the MH system, and all those who’ll come in the future, too.

When this ruling was initially announced, I was literally astonished to see mentally ill people and the charities that claim to represent us amongst those who were cheering.  I can’t help but wonder if they’ll still be cheering when they realise that, from now on, expressing the tiniest inkling of being suicidal will result in being locked up, pinned to the floor, and involuntarily medicated.  Perhaps the mentally ill people so treated will be comforted to know that all of this coercion and violence by agents of the state is taking place in ‘defence’ of their ‘human rights’.

Because that’s the other thing I find astonishing about this decision – that it was made under the auspices of the European Convention on Human Rights (EHCR), as adopted into UK law.  The convention was established in the aftermath of the Second World War, in part as a response to the atrocities that had taken place under the Nazi regime.  It’s aim was to defend the liberties and freedoms of all European citizens.  In many ways, it’s the ‘gold standard’ of human rights legislation around the world, but this is, of course, dependent upon it being interpreted in a sensible way by the courts that apply it.

Clearly, I’m not a legal expert, but this just doesn’t look to me like an occasion when the letter of the convention has been interpreted in accordance with its spirit.  It seems fairly obvious to me that this ‘defence’ of the right to life of individuals who want to kill themselves is going to result in the wholesale abrogation of other rights – the right to liberty under article 5 (violated by detention in a MH facility), or the right to privacy under article 8 (violated by 1-2-1 observations of patients), for example – for many individuals who pose no real risk of suicide.  It’s long been established that the right to life is the pre-eminent right, and that it ‘trumps’ all the others, but it seems to me this approach hits a huge stumbling block when the only way to ‘defend’ somebody’s right to life is to prevent them from acting in the way they choose.  It’s certainly not what the ECHR was designed to do.

The convention was designed to protect the individual against the actions of the state, not to force the state to ‘protect’ individuals against themselves.  It’s framers were envisaging situations in which individuals were abducted, tortured and killed by secret state organisations like the Gestapo or the Stasi, not situations where mentally ill people in hospital wanted to kill themselves.  I just can’t get over how perverse this judgement is – far from protecting the rights of the individual from state interference, the ECHR is actually being used to insist that the state interfere with the rights of the individual.  They’ve got things literally back-to-front.

This is (perhaps you can tell…) something I feel very passionately about.  I’m not in any way advocating suicide.  If someone I knew was feeling suicidal, I would spend as much energy and strength as I had trying to persuade them not to kill themselves.  I would strongly advise them to seek medical help.  If there’s anyone reading this who’s feeling suicidal, then I urge you to pick up the phone and talk to someone – friends, family, your GP, the Samaritans, anyone.  The way you’re feeling now is almost certainly temporary, and in a few hours or days or weeks you’ll be glad that you’re still alive.  Just the act of talking will almost certainly take some of the pressure off.

But I wouldn’t ultimately take any action that would force someone to do something they didn’t want to do.  I don’t think that I, personally, have the right to stop someone who really wants to die from killing themselves, and neither do I think that a psychiatrist, or a nurse, or a social worker, or a law lord, or anyone else, has that right.  I know this is a controversial view, and that it brings me into conflict, not only with the MH establishment, but also with lots of ex-inpatients who are profoundly grateful to the nurses and doctors who stopped them from killing themselves.  I’m afraid I still think I’m right, though.

Nobody can get physically inside anyone else’s head.  That seems like an obvious thing to say, and I doubt anyone would disagree, but it has consequences which most people seem to ignore.  No-one can have any idea of what somebody else is thinking, experiencing, and, most importantly, feeling.  There is no possibility of an independent assessment of emotional distress, there’s no way of finding out how much mental pain someone is experiencing.  Without that knowledge, there’s no way of offering treatment that you know will be effective.  Pump somebody full of enough heavy-duty medication and almost certainly they won’t kill themselves, but it’s impossible to know whether that’s because they no longer want to, or because they’ve been so heavily sedated they’re no longer able to.

The default assumption of most people who work in MH services seems to be that, once someone is diagnosed with a mental illness, any suicidal thoughts they have are a symptom of their illness and that, crucially, they’re temporary.  Often, of course, it’s 100% right to assume that.  It’s why I would so strongly urge anyone who’s feeling suicidal to – please – seek help.  I’d also agree that, when a patient first presents as suicidal, MH professionals need to proceed on the assumption that the suicidal thoughts are a temporary symptom, and that they can be treated with medication and other therapies.

But there also needs to be some kind of procedure in place for people who aren’t experiencing temporary difficulties.  There needs to be an opportunity for people, once they are beyond an immediate crisis, to express a sincere and settled wish to die.  It seems to me that the MH system as it’s currently set up simply doesn’t allow for that – active suicidal ideation will, whatever the circumstances, be taken as confirmation that someone is too unwell to make their own decisions.  The fallout from the HoL decision is just going to make that worse, in that lower levels of suicidal ideation will trigger a coercive response.

I fundamentally believe that mentally ill people are first-and-foremost people, and that we should be treated as such.  I think we are as entitled to our human rights as everyone else.  That means, of course, that we have a right to life, but it also means we have a whole slew of other rights – such as the right to privacy, and the right to freedom of movement.  The ECHR doesn’t specifically guarantee a right to self-determination, but it’s the underlying spirit of the whole convention – that we all have the freedom to do as we choose, provided our actions don’t infringe the rights of others.

This HoL decision – which applies only to those who are mentally ill and detained against their will – seems to recast the right to life as a duty to remain alive.  Those of us who are mentally ill no longer have an option, but must, by legal diktat, live, whether we wish to or not.  Moreover, it gives carte blanche for many other rights guaranteed under the ECHR to be abrogated if there are grounds to fear that a mentally ill person may fail in their ‘duty’ to remain alive.

As someone with mental illness, this decision doesn’t protect and enhance my human rights, it undermines and infringes them.  The mentally well have the right not to be killed against their will, but they also have the option to kill themselves if they so choose.  Only the mentally ill are to be forced to live against their will.  So much for human rights applying equally to us all.

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8 Responses to What price liberty?

  1. What, exactly, constitutes an open ward? One where there is someone on the door checking who comes in and out, but it’s not otherwise locked? Or one where patients can come and go as they please? If the latter, what is the earthly point of the ward?

  2. Madsadgirl says:

    Your last two sentences sum up the argument perfectly. It seems to me to be yet another form of discrimination against those with mental health problems. This time we are being deprived of the right to decide how and when we die.

  3. Lucy McGough says:

    Mrs Savage wasn’t necessarily suicidal. She had schizophrenia. Who knows what thoughts were going through her mind when she decided (if she did decide) to do what she did?

    This is an extremely tricky issue. Euthanasia is illegal in the UK, and I guess MH trusts who ‘let’ their patients die could be accused of passively aiding euthanasia.

    Yet again, I have to respond to this thorny question with a massive big “I don’t know.”

  4. aethelreadtheunread says:

    Thanks for the comments.

    DeeDee Ramona – What, exactly, constitutes an open ward?

    I’m afraid i don’t know what the exact situation was on the ward Carol Savage was detained on – i just used the decription i found in various newspapers of it being an ‘open ward’.

    what is the earthly point of the ward?

    I guess it was designed to function as some kind of halfway house, encouraging and preparing patients for a return to the outside world, rather than dumping them straight from ‘maximum security’ to ‘utter freedom’. Which actually sounds like quite a good idea. (The question of whether Carol Savage should have been on a less restrictive ward is a different one, of course.)

    Madsadgirl – It seems to me to be yet another form of discrimination against those with mental health problems.

    That’s certainly exactly how i see it, but with the added irritation (outrage?) that it’s being perpetrated in the name of a set of rules that is supposed to guarantee freedom from the effects of prejudice.

    Lucy McGough – Mrs Savage wasn’t necessarily suicidal.

    Depends how we define ‘suicidal’. If we define it as the desire to end one’s own life then i would say that, yes, she was suicidal. The inquest was in no doubt that jumping in front of the train was a deliberate act, so at that moment she must have been suicidal.

    Who knows what thoughts were going through her mind

    I deleted a couple of paragraphs that related to that issue (i’m trying to be less long-winded…), but i guess it might make sense to publish them here:

    Clearly, I don’t know enough about Carol Savage’s experiences to know what she would have chosen to do. She seemed to have enough of a ‘normal life’ to have a daughter and a husband, though this may just reflect the fact that her illness didn’t develop (or, at least, wasn’t diagnosed) until she was 30. But she was also something of a ‘revolving door’ patient – she was apparently hospitalised a number of times, and at least two of them were involuntary admissions. It would also appear that her hospital stays were of a fairly lengthy duration, suggesting that it wasn’t just a case of making sure she took her medication, and then waving her off into a happy, care-free life.

    Set out baldly like that it would appear that Carol Savage’s life may not have been a whole lot of fun, but the truth is, neither I nor anyone else can make that judgement. What matters is what her own experience of her life was like. It’s very possible she found more than enough pleasure in some parts of her life to counteract the times she felt miserable. It’s very possible she was selflessly devoted to her family, and would always have chosen to go on living so as to avoid causing them distress, whatever the cost to her personally. It’s possible that a sincere, long-standing wish to live was only briefly overturned by a temporary psychotic experience that the hospital should have recognised and taken steps to address.

    But it’s also possible that her life was a permanent living hell, and that she had been desperate to die for months, or even years. It’s possible that she had been looking for a way to do that for a very long time, and that her decision to jump in front of the train wasn’t taken on the spur of the moment in the midst of a temporary imbalance. It’s possible that she experienced not terror but relief in the final moments of her life.

    Euthanasia is illegal in the UK

    Given that no-one in the UK has ever been prosecuted for helping someone else to die, even when they have gone straight to the police and confessed their ‘crime’, i think there’s a question mark over how illegal it actually is. Technically illegal, certainly, but to all practical intents and purposes, not remotely illegal.

    The reason there’s never been a prosecution is, of course, that the prosecuting authorities know perfectly well that no jury would ever convict, and the reason for this is that, as opinion polls have repeatedly shown, most people in the UK support euthanasia. There are a minority of people who object on religious grounds and, because they have disproportionate access to the media, they’re holding the country to ransom, but at some point their stranglehold will be broken.

    I guess MH trusts who ‘let’ their patients die could be accused of passively aiding euthanasia.

    Euthanasia is a fairly specific concept – it means helping someone to die. So, if a MH trust allowed their staff to deliberately provide or administer a lethal dose of drugs with the specific aim of aiding the patient in ending their own life, they would be guilty of allowing euthanasia. Allowing a patient who has a rationally articulated and settled wish to die to leave the care of the MH trust and take matters into their own hands can’t, as far as i can see, be defined as aiding euthanasia, whether passively or otherwise. The fundamental issue is that expressing a wish to die will always be interpreted as evidence of mental instability.

    Yet again, I have to respond to this thorny question with a massive big “I don’t know.”

    As i see it, the key thing here is that people with a mental illness are being treated differently to those with a physical one. A patient with a physical illness is permitted to refuse treatment, even if that refusal will lead to their death. Why should that option be permanently denied to someone who was once diagnosed with a mental illness? If we are less deserving of human rights, doesn’t that mean we’re being identified as less than human?

    Sorry for the lecture, Lucy – i’m not attacking you personally, just trying to persuade you (and others) to my point of view. :o)

  5. Lucy McGough says:

    No worries, Aethelread. You’ve made some very interesting points.

    There is a good case for arguing that wanting to kill oneself is a sign of sanity.

    Do our lives belong to us? Are we even alive at all, or are we just a bunch of chemical reactions? Does Heaven exist? Do we owe it to our loved ones to stay alive? Does suicide set a bad example?

  6. cellar_door says:

    I was going to give you a proper response, but night shifts haven’t been kind to my brain. So this is a bit of a cop out :o)

    It’s such a difficult area. Like you say, Trusts can’t afford to be paying out huge amounts of compensation, and if they do, it impacts patient care. Although maybe they could fire a few unnecessary (sp?) managers instead, there’s plenty about. I’m now eagerly awaiting a new observation policy at work in response to this. Certainly the level of therapeutic risk (there’s another term for it I’m sure, but yeah, brain melt) we take at the minute will probably be hammered right down. Which is crap.

  7. Ah, thanks Aethelred. So a ‘rehab’ ward then, where the patients are deemed well enough to be out and about and not acutely ill.

  8. Pingback: Mental Nurse · This Week in Mentalists (67)

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