The priority of the good on the just one

Prinsen and van Delden ask if we can justify eliminating coercive measures in psychiatry, because the practice of coercive measures in psychiatry is controversial. They say also that because there are conflict between autonomy and beneficence/non-maleficence, human dignity, the experiences of patients and the effects of coercive measures, an appeal to respect autonomy and/or human dignity cannot be a sufficient reason to reject coercive measures. All together, these ethical aspects can be used both to support and to reject a non-seclusion approach. And so the authors argue that reasons such as respect for autonomy and the violation of human dignity are not sufficient reasons to eliminate seclusion. Altogether, at least in some interpretation, these norms can be used both to support and to reject a non-seclusion approach.

The precaution principle of "primum non nocere" should guide our actions. The authors choose a perspective of beneficence. This perspective is a good choice if beneficence is inserted not in the context of a pragmatic point of view that belongs to the theory of the principialism but in the context of the ethics of practical virtues.

I agree with Prinsen and van Delden that reasons such as respect for autonomy and the violation of human dignity are not sufficient reasons to eliminate seclusion. The mental illness is either a myth or scientific object or something else; but mental illness is real. And the patient above all is real and psychiatrists move in the effective and real practice with difficulties of personal, social and ethical character.

Asking "Can we justify eliminating coercive measures in psychiatry?" is a badly phrased question, since this is not a justice issue but an issue of being well and good, and is not an issue that we can justify.

I support the priority of being good and well on being just . I support with force the priority of practical reasoning. Also in medicine and in particular in psychiatry.

1. E J D Prinsen and J J M van Delden, Can we justify eliminating coercive measures in psychiatry? J Med Ethics 2009; 35: 69-73

Dangerousness criteria (1) are another source of discrimination against the mentally ill, but not the greatest.

There is a statistically and clinically significant association between violence and major mental illness, and some studies have demonstrated that major mental illness is associated with at least a fourfold increase in the chances of violence compared to the general population. (2)

However, a study showed (3) that the population impact of patients with severe mental illness on violent crime varies by gender and age, and that the population-attributable risk fraction of patients was 5%, suggesting that patients with severe mental illness commit one in twenty violent crimes.

On the other hand, rates of victimisation for people with severe psychiatric disorders are shown to be high and far greater than those for the general population, although men and women with severe mental ill ness tend to be seen as authors and not as victims of violence. (4)

The media continue to damage a very important part of society, made up of the mentally ill, their families and friends. News such as these are not unfrequent in the media:

'A mentally disturbed kills her father in Anywhere County'.

'A schizophrenic who stabbed his grandfather declared that he did it just to scare him'.

'A schizophrenic stabbed eight children and wounded 19 at a college'.

We should not believe that all people with schizophrenia do such things. Of the thousands of people who are diagnosed with schizophrenia in the world, only a small percentage has criminal behaviour. The rest live and let live. Most suffer from the disease in anonymity while their families and friends are socially discriminated by the community.

There should not be any discrimination in the treatment of people with illness in the media. Compare the previously reported headlines with these ones:

'An asthmatic kills her father in Anywhere County'

'A cirrhotic who stabbed his grandfather declared that he did it just to scare him'

'A nephrosclerotic kills stabbed eight children and wounds 19 at a college'

Will this be a reality someday?

We declare that we have not conflict of interest.

1. Large MM, Ryan CJ, Nielssen OB and Hayes RA. The danger of dangerousness: why we must remove the dangerousness criterion from our mental healthJ Med Ethics 2008;34:877-881.

2. Walsh E, Gilvarry C, Samele C et al. Predicting violence in schizophrenia: a prospective study. Schizophrenia Research 2004; 67: 247 252.

3. Fazels S, Grann M. The population impact of severe mental illness on violent crime. American Journal Psychiatry 2006; 163: 1397 1403.

4. Lovell AM, Cook J, Velpry L. Violence towards people with severe mental disorders: a review of the literature and of related concepts Rev Epidemiol Sante Publique. 2008 Jun;56(3):197-207.

In a study on the six due care criteria for lawful euthanasia in the Netherlands, H.M. Buiting and others found that the requirement that a physician should convince herself that her patient was suffering hopelessly and unbearably was by far the most difficult to meet. [1] Of the physicians who reported to have experienced problems with the criteria, 79% reported difficulties with that criterion; in particular they found it difficult to convince themselves that the suffering was unbearable, and only to a lesser extent that it was hopeless. Actually, the authors locate the difficulties even more precisely. 53% of the physicians indicated problems in assessing whether they themselves were convinced that the patient suffered unbearably, whereas 28% reported difficulties in assessing whether the patient experienced his own suffering as unbearable. Other criteria that were mentioned to cause problems relatively often were the requirement that the patient’s request should be voluntary and well-considered (58%), and that there should be no reasonable alternative available (33%).

The authors explain their findings by drawing attention to the fact that these three requirements are framed as open norms; ‘well-considered’, ‘unbearable’ and ‘reasonable’ all three requiring interpretation which has to take the specific circumstances of the case into account. Moreover, ‘well-considered’ and ‘unbearable’ (and to a lesser degree ‘reasonable’) refer to subjective aspects and are to a large extent a matter of the patient’s experience and personal perspective. This implies that physicians have to adopt an empathising role in order to ascertain whether the material criteria relating to the request are indeed fulfilled. But this need to empathise can get in the way of the physicians’ professional medical role, making their performance on the reasonable alternative criterion worse than it would be if their task were confined to the their medical role alone.

As a solution for the physicians’ problems, therefore, the authors suggest that ‘It should be clearly communicated [by the Dutch government, HW] that the patient’s suffering and request (apart from judging the patient’s competency) can be assessed objectively only to a very limited extent and that, accordingly, these aspects need to be left to the patient to a great extent.’ Physicians could then concentrate on their medical professional judgement to assess whether any reasonable alternatives are available. What the authors suggest, effectively, is solving the problem by eliminating it. Since it is difficult for physicians to assess whether a patient suffers unbearably to confine myself to the most troublesome criterion it would be better if they were spared the trouble and were permitted to leave the decision to the patients themselves. But that suggestion has some unwelcome consequences. It would, in the first place, turn the suffering criterion into a sham; a physician would satisfy the criterion simply by asking the patient if he suffered unbearably. If he answers ‘Yes’ that would be the end of the matter. But obviously, merely saying so does not make it so. Secondly, it would not turn just any old criterion into a sham, but the most fundamental one, the one on which the Dutch euthanasia regulation is actually based. To quote the authors once more: ‘Although self-determination of the patient is a necessary condition to justify termination of their lives, in the final analysis the physician’s responsibility to alleviate the patient’s suffering is the most important principle underlying the Act.’ Indeed it is, as has been convincingly argued by Den Hartogh. [2] If it took a physician no more to satisfy herself that her patient was suffering unbearably than simply to ask him if he did, if credibility on this score could be had for the asking, self-determination would be the fundamental moral ground of the Dutch euthanasia act after all, and not alleviation of suffering.

How, then, can a physician ascertain that her patient was suffering unbearably? Is it indeed a requirement she can only meet either by leaving it to the patient to decide or by abandoning her medical-professional role as the authors claim? That would be the case only if the medical- professional role is conceived in an inappropriately restricted way. As Cassell has argued extensively, among other places in the paper the authors refer to [3], medical knowledge consists of a lot more than knowledge of physiology, diseases and symptoms. Instead of directing all its attention to diseases and symptoms, ‘medicine should concern itself with illness, the set of disordered functions, body sensations and feelings by which persons know themselves to be unwell.’ [4] No general practitioner would dispute this view. At the very least, then, physicians always need to have particular knowledge about their individual patients, and if they have to assess their patients’ suffering, they have to know something in general about what makes a life go well, and hence, when it has deteriorated to a point at which it is conceivably not worth living any longer. Suffering is not a raw feeling, like pain or shortness of breath, but a complex state of being dependent on the particular meaning symptoms and losses have for this particular patient.

If it takes general knowledge about what makes lives go well and particular knowledge about this individual patient’s biography and character to assess his suffering, what does it take to know whether his suffering is unbearable? Does not that requirement draw essentially on the patient’s own point of view? Is not he the final arbiter on the unbearableness of his own suffering? No, again, saying that one suffers unbearably does not make it so. Rather it invokes a norm. The truth conditions of the sentence ‘I suffer unbearably’ are not met as soon as the patient believe they are, but when we, the Dutch political community, do. We determine which suffering we consider to be unbearable and which we expect anyone should be able to cope with. Such a norm is public, and no more subjective than any other public norm. Needless to say, what patients experience as unbearable and what we consider to be so overlap to a very large extent, but that does not rule out disagreement or conflict. In such cases, physicians should apply the open public norm, rather than taking her patient’s request at face value or foist her own norms on him.

In addition, then, to strict medical knowledge, physicians who have to decide whether to comply with euthanasia requests should have general and particular knowledge about what makes lives go well, and moreover, they must be acquainted with the public norm governing the application of the concept of unbearableness. Only this latter type of knowledge could possibly be called non-medical, since the norm in question is a societal norm in the sense that it is laid down in the Dutch criminal code, and interpreted by the courts and the regional review committees for euthanasia in which not only a physician, but also a lawyer and an ethicist serve as members.

References 1 Buiting HM, et al., Dutch criteria of due care for physician-assisted dying in medical practice: a physician perspective. JME 2008;34;e12. 2 den Hartogh GA, Het Nederlandse euthanasierecht: Is barmhartigheid genoeg? (in Dutch) Tijdschrift voor Gezondheidsrecht 2007;31:180-198. 3 Cassell EJ, The nature of suffering and the goals of medicine. N Engl J Med 1982;306:639-45. 4 Cassell EJ, The nature of suffering and the goals of medicine. New York: Oxford University Press, 1991: 49.

In response to your comments:

Ethics is about choices, but I do not agree that health care workers do not have choices. The choices available to us are obviously very varied. Some may well be able to change the number of nurses in a hospital (or have the ability to lobby for that kind of change). Alternatively in your cancer example, your choice may be just to turn the patient or to provide a cushion. The constraints are mental as well as physical and the Kenyan doctors you mention who are “working to improve the standard of care”, I would say are working against the constraints. The constraints could be teaching/learning about pressure sores. It is also not necessarily the individual doctors who are at fault but that a social and structural change and shift of thinking are needed to improve the situation in Africa. I am certainly not saying that Kenyan doctors, or any other group, are unethical and I think it over simplistic to categorize in this way. We make hundreds of decisions with a wide scale of ethics. A number of experiences in this article actually relate to European doctors working overseas. It is also not that practices in the UK are better than those in other parts of the world. Some are, some aren’t; most are just different. Accepting the status quo occurs everywhere but the situations tend to be much worse in the developing world. Not washing your hands between patients occurs every day in the NHS, but as there are generally less serious diseases and the patients are usually better able to cope, so the problems caused are comparatively less. The scenario is much worse if your infectious disease is cholera and your patient is a malnourished infant for example. I entirely agree that intensive care has a very small contribution to worldwide infant mortality. The point of that paragraph was that our target should be an IMR of a developed country but to get there is unrealistic due to the very high costs of intensive care. The role of the rich world certainly is important. This does not take up a large proportion of the essay because it is not primarily about this issue. I know it is easy to sit here and pass judgment, but are all practices/behaviours acceptable just because they occur in a society? I think there are universal standards that we, in admittedly very different ways, should be striving to achieve.