"Chartering" the limits of involuntary psychiatric treatment in Victoria: interpreting the Mental Health Act 1986 (Vic) in the age of the Charter of Human Rights and Responsibilities Act 2006 (Vic)

The Mental Health Act 1986 (Vic) allows for individuals with a serious mental illness to be treated on an involuntary basis either in a psychiatric hospital (on an involuntary treatment order) or in the community (on a community treatment order). The Act also establishes the Mental Health Review Board with the authority to review these orders within eight weeks of those orders being made and at least once every 12 months thereafter. This article analyses a recent decision of the board, Re Appeal of 09-085 [2009] VMHRB 1, in which the appellant challenged a decision of a psychiatrist to extend his community treatment order for a further 12 months. The appellant argued that aspects of his involuntary treatment under the Act amounted to "cruel, inhuman or degrading" treatment and therefore breached his right to freedom from "cruel, inhuman or degrading" treatment under s 10(b) of Victoria's recently enacted Charter of Human Rights and Responsibilities Act 2006 (Vic). Thus, the board was asked to consider whether the definition of "treatment" under the Act was compatible with the rights and freedoms enacted by the Charter. This was the first time that a Victorian court or tribunal had considered the impact of the Charter on involuntary psychiatric treatment. The decision was also a prelude to the Victorian Government's announcement that it would comprehensively review its mental health legislation, now the oldest in Australia. As this case highlights, in determining the future direction of mental health legislation and policy in Victoria, the Charter has been crucial.     

Law,Morality, and the Existence of Human Rights*

In the debate between positivism and non‐positivism the argument from relativism plays a pivotal role. The argument from relativism, as put forward, for instance, by Hans Kelsen, says, first, that a necessary connection between law and morality presupposes the existence of absolute, objective, or necessary moral elements, and, second, that no such absolute, objective, or necessary moral elements exist. My reply to this is that absolute, objective, or necessary moral elements do exist, for human rights exist, and human rights exist because they are justifiable.     

Endorsement of personal benefit of outpatient commitment among persons with severe mental illness.

This study examines whether individuals who experienced involuntary outpatient commitment (OPC) attribute benefit to this intervention. It was found that the majority of experimental subjects who underwent a period of OPC did not personally endorse OPC's benefits at the end of the study, either because they did not think it improved treatment adherence or because they rejected their own need for continued treatment. However, at the end of the study, a positive appraisal of benefit was roughly twice as likely among subjects who actually experienced positive treatment outcomes. These data provide little support for acceptance and "gratitude" as a rationale to support decision making about OPC continuation. Rather, clinicians need to rely on other clinical and empirical data for such decision making.     

A Retributive Argument Against Punishment

This paper proposes a retributive argument against punishment, where punishment is understood as going beyond condemnation or censure, and requiring hard treatment. The argument sets out to show that punishment cannot be justified. The argument does not target any particular attempts to justify punishment, retributive or otherwise. Clearly, however, if it succeeds, all such attempts fail. No argument for punishment is immune from the argument against punishment proposed here. The argument does not purport to be an argument only against retributive justifications of punishment, and so leave open the possibility of a sound non-retributive justification of punishment. Punishment cannot be justified, the paper argues, because it cannot be demonstrated that any punishment, no matter how minimal, is not a disproportionate retributive response to criminal wrongdoing. If we are to hold onto proportionality—that is, proportionality as setting a limit to morally permissible punishment—then punishment is morally impermissible. The argument is a retributive argument against punishment insofar as a just retributive response to wrongdoing must be proportionate to the wrongdoing. The argument, that is, is concerned with proportionality as a retributive requirement. The argument against punishment is set out on the basis of a familiar version of the ‘anchoring problem’, according to which it is the problem of determining the most severe punishment to anchor or ground the punishment scale. To meet the possible criticism that we have chosen a version of the anchoring problem particularly favourable to our argument, various alternative statements of the anchoring problem are considered. Considering such statements also provides a more rounded view of the anchoring problem. One such alternative holds that the punishment scale must be anchored not just in the most severe punishment, but in the least severe punishment as well. Other alternatives hold that it is necessary and sufficient to anchor the punishment scale in any two punishments, neither of which needs to be the most or least severe punishment. A further suggestion is that one anchoring point anywhere along the punishment scale is sufficient, because it is possible to ‘project’ from such a point, so as to determine the correlative punishments for all other crimes, and so derive a complete punishment scale. Finally, the suggestion is considered that one can approach the issue of a punishment scale ‘holistically’, denying any distinction between anchoring and derived (or ‘projected’) punishments.     

An Acquittal for Epistemicism

Scott Soames argues that consideration of the practice of legal judgement gives us good reason to favor the partial-definition/context-sensitive theory of vagueness against epistemicism. Despite the fact that the value of power-delegation through vagueness is evidenced in practice, Soames says, epistemicism cannot account for it theoretically, while the partial-definition/context-sensitive theory is capable of it. In this paper, I examine the two possible arguments against epistemicism that can be extracted from Soames’s account: (1) an argument based on unknown obligations, and (2) an argument based on power-delegation through vagueness. The first argument tries to convince us that, as based on epistemicism, the law has already decided the borderline cases, so that judges have obligatory decisions even in such cases: therefore epistemicism is inconsistent with the discretion of judges in borderline cases. I show that even if we sympathize with Soames’s intuitions concerning the legal practice, the argument he offers is not conclusive since it is either invalid, unsound, or paradoxical. The second argument holds that only the gaps which the partial-definition/context-sensitive theory predicts give judges the possibility of lawmaking in borderline cases. However, by categorizing the vague laws as imperfect laws, the judges can claim the right of lawmaking without any need to refer to gaps in the law. By neutralizing these arguments, I argue that epistemicism is able to explain the phenomena just as well as the partial-definition/context-sensitive theory.     

Perceived coercion and need for hospitalization related to psychiatric admission

Psychiatric hospitalization constitutes a moment of major stress to the point that occurrences of posttraumatic stress disorders have been described. Feelings of coercion are usual, whatever the legal status of admission. Patients may also consider afterwards that they needed hospitalization even if they refused it initially. A cross-sectional survey has been conducted among the inpatients of a Swiss psychiatric hospital to assess their subjective view of admission with emphasis on legal status, perceived coercion and need for hospitalization. Eighty-seven questionnaires were completed and analyzed. Results indicated that 74% of patients felt that they had been under pressure to be hospitalized, whether or not they were involuntarily admitted. Seventy percent felt their admission was necessary. More involuntary patients reported a subjective lack of improvement. Clinicians could decrease feelings of coercion of their patients while discussing need for hospitalization, legal status and subjective feeling of coercion as different dimensions. An argument is presented to favor positive pressure from social environment over legal involuntary commitment in many hospitalizations.     

The use of harmful to others-criterion for involuntary treatment in Finland

During the past decades the Western countries have paid attention to their Mental Health legislation, in particular, by making changes concerning involuntary treatment. In Western countries legislation allows involuntary treatment of the mentally ill. Involuntary psychiatric treatment is motivated by either potential harm to others (for the good of society) or by need for treatment and/or potential self-harm (for the good of the patient). The aims of this study were to describe to what extent the danger to others criterion is used as a motivation for involuntary hospitalization and detainment in Finland, and to what kind of patients this criterion is applied. The study involves a retrospective chart review of all the treatment periods of a six month admission sample in three Finnish university hospitals. We found that potential harm to others has been rarely used as a motivation for involuntary referral or detainment together with other motivations, and virtually never as the sole motivation. With the exception of gender, which was most often male, patients with potential harm to others did not differ significantly from other involuntarily treated patients. Coercion (defined as seclusion, the use of restraints, forced medication, physical restraint or restrictions in leaving the ward) was not used with these patients more regularly than with the patients motivated by the other criteria. Length of stay (LOS) in a psychiatric hospital did not differ between the patients determined harmful to others and the other involuntarily treated patients.     

Is embryo research and preimplantation genetic diagnosis ethical?

The legal position in the UK on embryo research and preimplantation genetic diagnosis (PGD) is outlined and contrasted with the position in other EU countries. The "gradualist" position of the UK on the moral status of the embryo is defended on the basis of an argument that precaution must be applied in proportion to the degree to which the embryo has developed to display components of agency, on the assumption that mortality is categorically binding and requires agents to be granted rights and that it cannot be known with certainty that the embryo is not an agent. The extent to which this argument, when combined with vicarious protections that the embryo should receive in order to protect the rights of other agents, limits embryo research and PGD, is discussed. It is concluded that the complexities that attend deliberation about the moral problems attending embryo research and PGD are such that the proper response to these problems is via the procedures of political democracy to achieve accountable answers rather than "correct" answers. This allows for a variety of judgements.     

Severe mental disorder as a basic commitment criterion for minors

Since 1991, commitment to involuntary psychiatric care has been allowed in Finland for minors in broader terms than for adults. While in adults mental illness has to be diagnosable before involuntary treatment can be imposed, minors can be committed to and detained in involuntary psychiatric treatment if they suffer from "severe mental disorders", and fulfil the further commitment criteria defined in the Mental Health Act. The first years of the new mental health legislation showed an increase in involuntary treatment of minors in Finland. Concerns were raised about the imprecise nature of the commitment criterion "severe mental illness". This study set out to find out whether Finnish child and adolescent psychiatrists are in agreement on how to define severe mental illness and whether their interpretations are sufficiently similar to ensure the equality of minors in commitment to psychiatric care as prescribed by the Mental Health Act. Semi-structured, reflexive dyadic interviews were carried out with 44 psychiatrists working with children and adolescents. The data was analysed using qualitative content analysis. There was general agreement about what constitutes a "severe mental disorder" justifying the involuntary psychiatric treatment of minors. The child and adolescent psychiatrists were of the opinion that involuntary treatment of minors should not be tied to specific diagnostic categories. Which disorders are severe enough to justify commitment should rather be considered through developmental and functional impairment and interactions between a minor and her/his environment.     

Correctness and Cognitivism. Remarks on Robert Alexy's Argument from the Claim to Correctness*

The argument from the claim to correctness has been put forward by Robert Alexy to defend the view that normative utterances admit of objective answers. My purpose in this paper is to preserve this initial aspiration even at the cost of diverting from some of the original ideas in support of the argument. I begin by spelling out a full‐blooded version of normative cognitivism, against which I propose to reconstruct the argument from the claim to correctness. I argue that the context of uttering normative propositions points to the possibility of normative cognition, but does not constitute it. What constitutes the possibility of cognition is, as of necessity, the propositional structure of norms. I conclude that the argument from the claim to correctness ought to safeguard a distinction between the context of uttering a normative sentence and the proposition that individuates the content of the utterance.     

The "untreatability" of psychopathy and hospital commitment in the USA

One argument in support of a public policy of not subjecting persons with psychopathic disorders to civil or criminal commitment is that these disorders do not improve with treatment. This article examines the relationship between the assumption of untreatability of psychopathic disorders and outpatient civil commitment, inpatient civil commitment, and insanity acquittee commitment. Research on the treatability of psychopathy is reviewed and the treatment of conditions co-morbid with psychopathy is considered. Research evidence is insufficient to support the conclusion that psychopathy is improved, worsened or not affected by treatment. Evidence does support effective treatments for conditions that can be co-morbid with psychopathic disorders including impulsive aggression which can be interpreted as a manifestation of psychopathic disorder.The absence of evidence based treatment efficacy for psychopathic disorders is a logical reason for not subjecting individuals with only a psychopathic disorder to involuntary hospitalization. This assumption should not becloud the possibility of treatable co-morbid conditions which may or may not qualify for involuntary hospitalization. Where the primary mental disorder, for which an individual is involuntarily hospitalized, results in behavioral improvement, the continued presence of a psychopathic disorder itself, should not be sufficient reason to continue coerced confinement. Even so, where the primary disorder is incompletely treated, psychopathy can be considered a risk factor when deciding upon the appropriate time for discharge and when formulating a safe and effective after care plan.     

Litigating life and death.

In cases involving the "right to die," courts are faced with the agonizing task of developing legal standards governing termination of an incompetent patient's medical treatment. In this Article, Professor Rhoden criticizes the two dominant approaches courts have developed--the "subjective" and "objective" tests--and proposes that these standards be abandoned for a legal presumption in favor of family decisionmaking. She maintains that the "subjective" test, which requires the family to provide clear proof that termination of treatment is what the incompetent would have chosen, is often unworkable because a patient's character traits, and even her prior statements about medical treatment, seldom rise to the evidentiary level that courts purport to require. Similarly, she argues that the "objective" test, which requires the family to prove that the burdens of the patient's life, measured in terms of pain and suffering, clearly and markedly outweight its benefits, dehumanizes patients by suggesting that only their present, physical sensations count. Professor Rhoden suggests that the subjective and objective tests are not nearly as distinct as courts have made them. She argues that the rigidity of these legal standards reflects courts' acceptance of the medical profession's presumption in favor of continued treatment, a presumption that places a heavy burden on families seeking to terminate treatment. Drawing on the special qualifications of families as decisionmakers in such cases, Professor Rhoden proposes that courts recognize a presumptive right of families to exercise discretion over treatment decisions. Such a standard would recognize that, although doctors and others can readily prove that terminating the treatment of a patient who can still enjoy life is wrong, it is very hard for families to meet the current standards, which essentially require them to prove that termination is right.     

Fault-lines in community treatment order legislation

This article discusses the major tension points in the legislation that authorises involuntary outpatient treatment for mental disorder in six British Commonwealth jurisdictions. Particular attention is paid to the role of competence (or capacity) principles in the ruling legal criteria, to the precise powers of community treatment conferred, and to the potential impact of the legislation on clinicians' liability concerns. It is argued that the conferral on clinicians of a power to administer 'forced medication' in community settings is not required to promote active use of involuntary outpatient care, and that such a power should not be provided. The article concludes with discussion of the reasons why community treatment orders are used more frequently in some jurisdictions than others.     

Regulating germ-line gene therapy to avoid sliding down the slippery slope

Many arguments can be made for or against various regulatory approaches towards germ-line gene therapy and its associated research. A popular conclusion is that it ought to be prohibited, and this is commonly defended by use of a slippery slope argument. This paper will begin by outlining the regulatory approaches adopted towards germ-line gene therapy in EU countries, demonstrating the popularity of the restrictive approach. The slippery slope argument will then be examined. A number of variants of the slippery slope argument will be distinguished, highlighting the conceptually different claims made by each. Finally, examples of slippery slope arguments often invoked to support the prohibition of germ-line gene therapy will be examined with regard to the conditions that each must satisfy to form a theoretically sound argument. I will argue that these conditions are rarely given sufficient consideration. For the purposes of this paper, "germ-line gene therapy" is defined as the deliberate genetic modification of germ cells (sperm or oocytes), their precursors, or the cells of early embryos where the germ-line has yet to be segregated.     

What medical school did you graduate from? Judicial prescribing of medical treatments

There is much in the literature concerning conflicts between clinicians and the law over who should make decisions in a legal context, such as involuntary hospitalization or patients' competency to make treatment decisions. There is little, however, about judges' trying to impose specific treatment decisions on clinicians. This article addresses that situation and the problems such orders cause.     

Can Strict Criminal Liability for Responsible Corporate Officers be Justified by the Duty to Use Extraordinary Care?

The responsible corporate officer (RCO) doctrine is, as a formal matter, an instance of strict criminal liability: the government need not prove the defendant’s mens rea in order to obtain a conviction, and the defendant may not escape conviction by proving lack of mens rea. Formal strict liability is sometimes consistent with retributive principles, especially when the strict liability pertains to the grading of an offense. But is strict liability consistent with retributive principles when it pertains, not to grading, but to whether the defendant has crossed the threshold from noncriminal to criminal conduct? In this essay, I review the two most plausible arguments supporting an affirmative answer in the context of the RCO doctrine. First, perhaps this doctrine reflects a rule-like form of negligence, akin to a rule that prohibits selling alcohol to a minor. Second, perhaps this doctrine expresses a duty to use extraordinary care to prevent a harm. Neither argument is persuasive. The first argument, although valid in some circumstances, fails to explain and justify the RCO doctrine. The second argument, a duty to use extraordinary care, is also inadequate. If “extraordinary care” simply means a flexibly applied negligence standard that considers the burdens and benefits of taking a precaution, it is problematic in premising criminal liability on ordinary negligence. If instead it refers to a higher duty or standard of care, it has many possible forms, such as requiring only a very slight deviation from a permissible or justifiable standard of conduct, placing a “thumb” on the scale of the Learned Hand test, identifying an epistemic standard more demanding than a reasonable person test, or recognizing a standard that is insensitive to individual capacities. However, some of these variations present a gratuitous or incoherent understanding of “negligence,” and none of them sufficiently explain and justify the RCO doctrine.     

Science and the Death Penalty: DNA, Innocence, and the Debate over Capital Punishment in the United States

The death penalty debate in the United States has recently undergone a fundamental shift. The possibility of executing the innocent has emerged as some abolitionists' most salient argument, displacing debates over such issues as fairness, deterrence, and cost. Innocence has managed to move to the fore of the debate in part because of the success of death penalty opponents in attaching epistemological certainty to one particular category of postconviction exonerations, those vouched for by the authority of DNA evidence. We suggest that such moves are primarily rhetorical because, while DNA evidence may be more accurate and reliable than other forensic science, it still fundamentally probabilistic in nature and is prone to uncertainties at all stages of its production. Yet, because of the certainty attached to DNA evidence in public discourse, it can be used as a lever with which to challenge law's claims to truth-making authority, and to undermine public trust in the death penalty. A few abolitionists and other scholars have expressed misgivings about the abolitionist embrace of the innocence argument. We push this concern further, suggesting that both abolitionists and death penalty reformers, who seek to promote a "scientific" death penalty centered on DNA evidence, draw upon a mythologized notion of "science" as a producer of epistemic certainty.     

Trends in involuntary psychiatric hospitalization in Israel 1991-2000

BACKGROUND: Though information about involuntary psychiatric hospitalizations (IPH) is crucial for the planning of Israel's National Mental Health Care Policy, very few studies have been carried out to date on this subject. AIMS: To identify trends in first IPH to all inpatient psychiatric settings in Israel. METHOD: The sample included all admissions of adults (18 years and older) over the ten-year period, 1991-2000, according to the registration of such admissions in the National Psychiatric Case Registry. RESULTS: A 2.4-fold increase was found in first IPH over the decade studied. The typical profile of the involuntarily admitted patient was that of a native-born Jewish male, aged 18-24 or 65 and older, single, with less than 8 years of education, and with a diagnosis of schizophrenia or delusional psychosis. CONCLUSIONS: These findings suggest the need for improving the interfaces between hospital and community services, and for preparing specific guidelines to extend the use of involuntary ambulatory treatment orders. Further study is needed to explore the respective roles of involuntary inpatient and outpatient treatment.     

Legal,ethical and clinical implications of prescribing involuntary,life-threatening treatment: the case of the Sunshine Kid

Involuntary treatment is a concept often familiar to psychiatrists. In clinical practice, it usually involves the hospitalization and pharmacological management of patients with severe mental disorders. However, the scope of involuntary treatment is not limited to the management of mental illness alone. Psychiatric patients afflicted with medical illnesses may require hospitalization and invasive procedures for optimal management of these disorders. The following case illustrates a dilemma in which a psychotic patient refuses life-saving medical treatment; however, the treatment itself carries significant risk of morbidity and mortality. This article reviews the ethical, legal and clinical implications of making such difficult treatment decisions.     

Rewriting Roe v. Wade

Presented in this essay are suggestions for rewriting Roe vs. Wade, the case that resulted in the establishment of a constitutional right to abortion. Essentially, the argument is 1 of equal protection. It is suggested that abortion be viewed as presenting a problem that might be termed "the law of samaritanism" -- the law regarding obligations imposed on certain individuals to provide assistance to others. In American law it is a deeply rooted principle that an individual is ordinarily not required to volunteer assistance to another individual who is in danger or in need of aid. The argument presented maintains that if a pregnant woman is required to carry the fetus to term and deliver it, then she is being compelled to be a Good Samaritan. It is argued further that if the generally limited scope of obligations of samaritanism under current law are considered, and the special nature of the burdens imposed on pregnant women by laws forbidding abortion are also considered, the obvious conclusion is that the equal protection clause forbids imposition of these burdens on pregnant women. The argument is developed in a lengthy form and calls for an extended discussion of the law of samaritanism. The uniqueness of the abortion case also creates problems as the equal protection argument is approached, and an approach to equal protection questions is sketched.