§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. James Hamilton.]
§ 3.46 a.m.
§ Mr. Christopher Price (Lewisham, West)
I suspect that fourteen minutes to four in the morning is hardly a suitable hour at which to raise the subject of the compulsory treatment of psychiatric patients. Many people in the country might compare the behaviour of this House with that very concept. However, this is a subject that needs close consideration by this House and, late though the hour is, I am happy that the Minister of State, Department of Health and Social Security, has decided to answer the debate, because I believe that there are some very important points to answer.
Normally when this subject is raised Parliament interests itself in such matters as more secure accommodation and the protection of the public from psychiatric patients. My point this morning is very much the opposite to that situation. I am interested in the civil liberties of patients as citizens in psychiatric hospitals.
I believe that there is some genuine anxiety about this matter in the country. The recent film "One Flew Over the Cuckoo's Nest" highlights some of those anxieties. Those anxieties have arisen because the public is slowly realising that psychiatric treatment is not nearly as reliable or as certain as many psychiatrists make it out to be, or as once it was thought to be. The track record of psychiatrists over the years is not very good, as I know the Minister will accept. In the nineteenth century they were obsessed with masturbation; a few years ago they gave insulin treatment and then dropped it.
Although many psychiatrists are fairly modest and cautious in their claims, others are not. A recently published book by Anthony Clare, "Psychiatry in Dissent", quotes Dr. William Serggant as saying:Conscience can now be eliminated surgically without any impairment of day to day working efficiency.The existence of professional arrogance of that kind and the fact that psychiatry 1160 is the only form of medicine where compulsory treatment is administered make it necessary for Parliament to pay special attention to this problem.
Broadly, I want to raise three aspects. The first concerns the use of electroconvulsive therapy, known as ECT. There has been a good deal of disquiet for some time about this. It was made clear on 22nd February this year in a report in The Sunday Times which summed up the three worries as being:Many psychiatrists believe that ECT causes some degree of long term memory loss.No properly controlled clinical trial has been made of ECT as a treatment for depression…Patients have a legal right to refuse ECT treatments even if they are compulsorily detained in mental hospitals and even if they change their mind after previously signing a form giving consent for treatment.The Department of Health and Social Security seems to gather no statistics whatever about the number of ECT treatments that are performed. This is one of those extraordinary operations where, although it seems to work in some cases, no one can give a scientific explanation why it works. It has been described as being rather like kicking the television set. It has the same sort of success.
Doubts and worries about ECT and the way it is used in hospitals have been enormously increased by the recent and excellently written report of Mr. Inskip QC on the state of affairs at St. Augustine's Hospital, Canterbury. I draw my hon. Friend's attention to two incidents in the report. The first is described as "Incident 6" where a man described as "Mr. G H I" an informal patient, received 30 treatments, many of them without specific authority from the doctor, and ended up with organic cerebral deficit.
"Incident 67" concerned a "Mrs. J K L" who was admitted to hospital with a broken back. She was not examined by her doctor. She had to be carried by four nurses. This woman was given ECT treatment which the doctor ordered without examining her. She died five days later. Both these incidents concerned one doctor. The report makes it clear that St. Augustine's Hospital was not untypical and was no different from 1161 any other psychiatric hospital in the country. The report says of ECT:These incidents"—the two I have related—show how unreal a patient's supposed consent often is, and how tortuous are some of the arguments resorted to in order to avoid facing reality. It is no wonder that there have been unhappiness and misunderstandings in some staff, particularly the younger ones. We are satisfied that a degree of force that exceeds any legitimate persuasion has been used to administer ECT to unwilling informal patients on many occasions. Indeed, it has attracted a jargon of its own.The report says that doctors did not refer to "force" but to "support".
I have three questions to ask. First, when will the consultative document which will embrace consideration of the ethical nature of these treatments be published? Secondly, what is the Secretary of State doing about the state of affairs shown up at St. Augustine's, and, thirdly, who is responsible for the criminal acts which the report to which I have referred reveals? Is it the responsibility of the Minister or the profession to take action to deal with these criminal acts?
I pass on to psychosurgery, another treatment which has caused a great deal of worry recently. It is a substantial operation which needs a patient's consent. In the past there is no doubt that it has been abused. In The Sunday Times of this week, Dr. Henry Rollin is quoted as saying:My own hospital is littered with the wrecks of humanity who, in the heyday of this operation 20 years ago, were given little or no option but to undergo prefrontal leucotomies for a variety of psychiatric conditions.I know that it is not like that anymore. Recently Brook Hospital, where most of the psycho-surgical operations take place, invited three Members of Parliament to visit. I was one of the three, and I was impressed by the lengths to which the authorities went to obtain patients' consent. I was also impressed by the advances in this treatment. However, this was in contrast with a recent television programme put out by Yorkshire TV, called "It's a Bit Frightening". This programme showed a form of psycho-surgery condemned by many psycho-surgeons in the country, and to me it was very frightening indeed. Many people say that this treatment was just as rough 1162 and ready as the old prefrontal leucotomy.
I urge my right hon. Friend to take this deep concern about psycho-surgery very seriously, particularly in view of the fact that the Medical Research Council has been asked by the Royal College of Surgeons for a grant to monitor psychosurgery. It is not a grant to experiment into methods but the danger of getting a large research grant for an operation of this kind, which should be applied in only a tiny number of cases, is that the assistance of that research money increases the number of operations which take place quite unnecessarily. If the Minister has any information about when the MRC is likely to make a final decision on this grant, we would be keen to hear it.
The third subject is the whole area of chemotherapy—the use of drugs on psychiatric patients. At the moment no consent form is needed for many of these drugs, although the effect of psycho-tropic drugs can be more far-reaching than ECT, for example. The Minister of State will remember that in the St. Augustine's report one charge not found substantiated was that there was too heavy use of chemotherapy. The report said that the words "too heavy" were wrong because every single psychiatric hospital in the country indulges in heavy use of these drugs—of phenothiazines. It has been said that modecate and largactil have replaced the padded cell—by drugging patients so that they do not need to be locked up.
Although some psychiatrists consider that these are wonder drugs and are happy with the enormous increase in their use, many people are extremely concerned. These drugs have not been on the market long enough for long-term trials to have been done about the long-term effects they have.
When the Minister prepares his consultation document about consent procedures, will he include in that as well as some canvassing on whether chemotherapy should be included with ECT and psycho-surgery, the consideration whether certain forms of drugs should be included with these other treatments which at the moment need consent? There is a great deal of worry among psychiatric patients about this point. They feel that they are being subjected 1163 to drugs about which they know nothing and which have an effect on their personalities for the rest of their lives.
Has my hon. Friend seen statements put out by the Hackney Patients Union? Those who have seen the sort of spasms which can be induced through the use of some of these drugs believe that very much greater control over their use and proper procedure are necessary. My hon. Friend told me on 13th February that there was to be a review of the psycho-tropic drugs. How is that review going and when may we have the results of it?
I wish to deal with the exact position about consent procedures. It seems clear that informal patients have the absolute right, in theory, to refuse treatment. But everyone knows the meaning of the threat of being sectioned in hospital, with the loss of privileges and the risk of discrimination. As at St. Augustine's hundreds of informal patients receive treatment against their will and without proper consent procedures.
What is the position for formal patients? Clearly, people covered by Section 26 of the Mental Health Act can receive treatment against their will, but many doctors believe that patients detained under Section 25 for observation can also receive treatment against their will. Will my hon. Friend make some sort of definitive statement about whether it is legal to give compulsory treatment under Section 25? I have constituents who have faced this problem.
I hope that the Minister will be able to suggest in the consultation document some tightening of the law and some method to ensure its enforcement. I hope that he will suggest also methods of changing the attitude in the professions, both medical and nursing, to create a far greater respect for the patient as a human being and less reliance on sheer mechanical methods to create docility in psychiatric hospitals. It is no good just relying on the law. We need a strengthening of the law if we are to surmount the situation in our hospitals.
In the long run I believe that it is only when the doctors and nurses realise that they have a job to do in co-operating together in both caring for and treating by medical methods psychiatric patients that we shall get this right. The St. 1164 Augustine's report has caused very widespread worry both in the professions and among the public, and the Minister should be in a position to say something to reassure people.
§ 4.4 a.m.
§ The Minister of State, Department of Health and Social Security (Dr. David Owen)
I am very grateful to my hon. Friend the Member for Lewisham, West (Mr. Price) for raising this important and difficult subject tonight. It is important because patients in our mental hospitals and general hospital psychiatric departments are, perhaps in more ways than most other types of patient, often not in a strong position to be able to speak up for themselves and look after their own best interests. There is a great responsibility on us all, particularly on medical and other staff caring for patients, to ensure that both legal and ethical boundaries are not transgressed.
My hon. Friend talked about concern. There is concern and I share it. This is a difficult subject. It is necessary to maintain a fine balance between two conflicting considerations: on the one hand the patient's right to treatment and the importance of ensuring that treatments of proven efficacy continue to be made available to patients who could benefit from them, sometimes when all other possible treatments have failed; on the other, the danger of abuse, about which my hon. Friend has spoken, and the need to ensure that patients' legal and civil rights and their freedom of choice are fully maintained.
Nearly 90 per cent. of all psychiatric in-patients, as well as all those making up the 1½ million psychiatric out-patient attendances and over 2 million day-patient attendances each year, are informal. That is to say, they are free to come and go as they please; they are free to refuse any form of treatment and medication; and they may discharge themselves from hospital without notice or against medical advice if they wish. No problems should arise on questions of consent to treatment in respect of such informal patients because they are at liberty to refuse any treatment which they object to and, ultimately, are at liberty to discharge themselves from hospital if they so wish.
With regard to detained patients, the Mental Health Act 1959 makes no 1165 specific provision for the obtaining of a patient's consent to treatment. In the case of treatment involving any special risk, the patient, if he is capable of understanding, and the nearest relative should be told what is proposed and the consent of both should if possible be obtained. In practice, a form of treatment involving any special risk should not normally be administered if the patient or his nearest relative objects.
However, where treatment is considered necessary to preserve the life or health including mental health of the patient, it is thought that the administration of such treatment would be unlikely to be questioned particularly if the consent of the nearest relative had previously been obtained. That is the advice that has been given. I may say that a similar interpretation of the law is given by the Medical Defence Union in its booklet "Consent to Treatment".
A number of bodies have expressed some anxiety about the position of a detained patient with regard to treatment, and I would assure my hon. Friend and the House that the comments they have made will be taken fully into account by the interdepartmental committee which is reviewing the Mental Health Act. A consultative document will be published later this year.
All those who have expressed views agree that some kind of additional protection is necessary, at least where the doctor wishes to carry out a radical form of treatment to which the patient does not consent. The Davies Committee on Hospital Complaints Procedures has recommended that a second and independent medical opinion should be obtained in any decision to impose treatment on a detained patient; the Royal College of Psychiatrists feels that a second medical opinion should be sought if the treatment proposed is liable to have irreversible or long-lasting effects; the Report of the Butler Committee on Mentally Abnormal Offenders contains a very full and useful discussion of the issues involved and it goes on to recommend a procedure which would require a second opinion to be sought before what it terms an "irreversible or hazardous" form of treatment is carried out on a detained patient.
1166 The Butler Report also sets out a formula which provides that only the minimum treatment necessary to prevent a patient from being violent, to save his life or to prevent him from deteriorating should be imposed on him if he is able to appreciate what is involved. The National Association for Mental Health, MIND, has produced a special report on the Mental Health Act written by Mr. Larry Gostin, its legal and welfare rights officer. In this very interesting report, the issue of consent to treatment is discussed at some length and it is suggested that as a solution to the problem a network of committees on the rights and responsibilities of staff and residents of psychiatric hospitals should be set up at national and regional level alongside an advocacy system with the primary functions of making a judgment on the validity of the consent given by a patient to an irreversible or hazardous form of treatment, and providing a second opinion on a proposal to carry out treatment where the patient is incapable of giving a valid consent. The consultative document will discuss all these different suggestions and invite comment on them.
In regard to psychotropic drugs, there is a problem of definition of treatment. We shall be discussing consent to treatment. The committee which is reviewing medicines has already set up a sub-committee to look into the safety and quality of psychotropic drugs. I do not know when the work will have been finished, but it is the earliest category that has been undertaken.
I now refer to my hon. Friend's points on the specific issues. The position is that ECT has been used in this and other countries for approximately 40 years. It is generally regarded within the psychiatric profession as of great and proven value to many patients, especially in the treatment of depression, one of the most common psychiatric illnesses. In deciding whether to administer it, psychiatrists have to take into account a number of factors—not only the patient's diagnosis, but the seriousness and characteristics of his condition, his age and so on. They are generally very much aware that it can cause patients considerable anxiety and accordingly recognise the desirability of giving no more treatments than are 1167 necessary. The average number of treatments given to patients suffering from conditions for which ECT is considered beneficial is normally about six, usually given twice weekly.
There have been controlled clinical trials into the use of ECT, and these indicate that it is quick in producing a beneficial response and free from serious side effects. The MRC has advised that there is no evidence that ECT given in the proper manner and with proper safeguards causes brain damage, a commonly made criticism of this treatment. My hon. Friend has mentioned two rather horrifying cases of abuse that have been commented on in the recent report. Comments of especial relevance to this debate are contained in the report. The first dealt with the efficacy of ECT against possible drawbacks in the treatment. It stated: " It is probably the most effective treatment for moderate or severe depressive illness…and those using it must, as in all forms of treatment, consider whether the expected benefits from it outweigh the risks and disadvantages." My hon. Friend asked who is responsible for handling the St. Augustine report. It will require action by the regional health authority in as much as the authority is the employer of some of the people concerned. The area health authority employs the other staff. The report is being sent to all regional health authorities, area health authorities and districts.
We think that some of the lessons contained in the report are of common application. My hon. Friend will know that my right hon. Friend the Secretary of State has visited St. Augustine's and has made it quite clear that he intends to give special attention to the problems of mental illness in the light of his longstanding interest in this topic. He is considering what measures we can undertake to try to prevent a repetition of this and other incidents in some of our psychiatric hospitals.
§ Mr. Christopher Price
Will my hon. Friend consider drawing the St. Augustine's report to the attention of the professions, so that if necessary they can take the sort of disciplinary action with which Parliament has charged them?
§ Dr. Owen
The only body of disciplinary action is the General Medical Council. I should be surprised if the council has not read a copy of the report. It is, of course, charged by Parliament, but it is independent of Parliament. The whole basis of the system is that it is a self-regulating profession. However, I shall ascertain whether a copy of the report has found its way to the council. The other copies are for the employing authorities.
My hon. Friend mentioned psycho-surgery. I recognise that this is a matter that causes concern. It involves the division of brain tissue with the aim of relieving psychiatric symptoms and is usually performed when all other forms of treatment have proven unsuccessful, when the condition is chronic and only in very carefully selected cases. It is very rarely performed at all on detained patients, even those anxious to receive treatment, and those informal patients who undergo the operation will need to have given their informed consent to it.
A number of scientific studies, some of them of high quality, are available which bear on the effectiveness and risks of psycho-surgery as now performed. From these studies it is clear that it has been of considerable benefit to some patients. As regards the specific research projects that the MRC is now considering, I am informed that consideration of the application is still at a preliminary stage.
My hon. Friend also mentioned anxieties about chemotherapy. There is cause for concern when too undue a reliance is placed on chemotherapy, but I must stress to him and to people generally that psychiatric illness can be very severe. It is not the same as an illness which requires an operation, or involves risks which are normally associated with operations. We should not forget that depression is an extremely common cause of suicide whereas severe pain very rarely leads to suicide. Depression and many psychiatric illnesses are very severe illnesses.
It is therefore reasonable for doctors to weigh up very carefully the balance of advantage to the patient. Sometimes they will advise treatment which, without doubt, may have in isolation some risks 1169 attached to it, and some disadvantages. They have to make that most difficult judgment of all—namely, what is in the best interests of the patient.
It is right, however, that Parliament should consider the safeguards that we already have in our existing law, and in practice, with great care. It is a difficult balance that has to be made and I think it is time that we had a substantial review of the workings of the current Act. I hope that the consultative document that we shall publish will stimulate a wide debate and that we can reach some consensus on the changes and adaptations to the Act that are needed, and that the legislation can come before the House within a reasonable period. I think that everyone would accept that.
1170 The Mental Health Act paved the way in this country with substantial changes of great benefit to patients. In many ways it was a pioneer in the world. It now needs to be examined. We now need to consider patient rights with extreme care.
I shall not forget the points that my hon. Friend has raised in this debate. They will go forward into the coming debate on the Act. I am grateful to him for bringing these important issues to us.
§ Question put and agreed to.
§ Adjourned accordingly at sixteen minutes past Four o'clock a.m.