759
THE LANCET Law and Mental Disorder MENTAL-HEALTH legislation is as subject to fashions and cycles as any other area of law. Most of the commitment laws stressing judicial or police involvement were enacted in the middle of the 19th
century. Emphasis on formal structures and court review continued during the asylum era, in the course of which the mentally ill and the retarded were segregated and generally lost their legal capacity and their civil rights. Not until the middle of this century did alterations in treatment methods and public attitudes towards the mentally ill have an effect on the Law. After 1950, mental-health legislation in most developed countries was substantially revised. Yet the British Mental Health Act of 1959 has been much criticised. Since 1975 proposals for change have come from the Royal College of Psychiatrists,2 the National Association for Mental Health,3,4 the British Association of Social Workers,5 and the Butler Committee;6 a
conference of interested parties followed the appearance of a consultative document;’ and now we have the long-awaited white-paper.8 The present cycle is characterised by four main aspirations. The first, and a principle enshrined in the report9 which inspired the 1959 Act, is that people with mental disorder should as far as possible be treated in the same way as those with physical illness. Secondly, treatment whenever possible should be voluntary, involuntary measures being reserved for emergencies and the last resort. Thirdly, special legal "labelling" of the mentally retarded should be abolished and these people should have the same access as other citizens education and rehabilitation. to appropriate Fourthly, the mental-health programmes should be integrated into the general health and social services, particularly at their point of delivery in the hospitals and the community. So, after all the discussions, proposals and counter proposals, how do the Government’s recommendations stand up? The growth of psychiatric units within district general and teaching hospitals, the increasing interest shown in the provi-
one-day
1
Curran,
W. J.,
Harding,
T. W. The Law and Mental Health:
Harmonising
Obiectives.World Health Organisation, Geneva, 1978. 2 Royal
of
Psychiatrists’ Working Party. Br. J.Psychiat. notes and news suppl, October, 1974. 3 Gostin, L O. A Human Condition. The Mental Health Act from 1959 to 1975 London, 1975. 4 Gostin, L. O. A Human Condition. The Law Relating to Mentally Abnormal Offenders. London, 1977.
College
5 Mental Health Crisis Services—A New Philosophy. British Association of Social Workers, Birmingham, 1977. 6 Report of the Committee on Mentally Abnormal Offenders. Cmnd 6244. H M. Stationery Office, 1975. 7 A Review of the Mental Health Act 1959. H.M.Stationery Office, 1976. 8 Review of the Mental Health Act 1959. Cmnd 7320. H.M. Stationery Office, 1978 9 Report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency.Cmnd 169. H.M. Stationery Office, 1957.
sion of effective psychiatric treatment within the area of primary health care, and the greater awareness of psychological and social factors in the genesis of ill-health, physical as well as mental, are all pointers towards a greater integration of the psychiatric and medical services. Such features which still discriminate against the mentally ill and
retarded-e.g., inadequate facilities, shoddy food, and poor staffing-are more likely to be corrected by a diversion of Health Service funds than by legislation. Much pride is rightly taken in the fact that over 90% of admissions to psychiatric hospitals and units in Britain are voluntary and the white-paper endorses the principle that mentally ill people should as far as possible be on equal footing with physically ill people. So it is odd to find the document proposing that informally admitted psychiatric patients should be given a statement of their legal rights on admission to hospital. Is it suggested that all patients admitted to hospital in Britain, the physically ill as well as psychiatric patients, should be given such a statement and if not why not? After all, a patient with chronic renal disease often has as good reason to know his civil rights as a patient with phobic anxiety. Similar contradictions surround the discussion of the concept of informed consent. The National Association for Mental Health muddied the waters by asserting that a sizeable number of patients admitted informally are acting under coercion by relatives and doctors.10 Such allegations have been contested vigorously by psychiatrists who maintain that often the only person competent to decide whether a patient is giving informed consent is the doctor in charge of the patient: it is for the doctor, they say, to make the clinical decisions and obtain consent to admission and treatment while it is for the patient, or whoever is acting in his interest, to decide whether to accept admission and the treatments proposed. There seems little sense in a distinction in Law between the consent uttered by an informal psychiatric patient and that given by a patient faced with medical, surgical, or dental treatment. In the event of an informal patient being judged unable to give proper consent, then the same arrangements should govern the decision about psychiatric treatment as would apply to any other similarly incapacitated non-psychiatric patient. Whether the decision is to be made by a multidisciplinary panel or by peer medical review, the same procedure should surely apply to a surgical operation as to electroconvulsive therapy. Provisions for informal consent need form no part of any mental health act. There is further confusion over "hazardous" treatments. Influenced no doubt by MIND’s submissions on the subject, the white-paper defines these treatments as those "where the risk of adverse reaction or the severity of such reaction would be disproportionate to the degree of benefit the treatment is likely to confer or the prospect of success". It is difficult to see how any doctor could employ such treatments without running a serious risk of legal action, so why does the white-paper interest itself so closely in the control and regulation, whether medical or multidisciplinary, of such unethical practice. 10. Gostin, L. O A Human Condition The Mental Health Act from 1959 to 1975 London, 1975.
760
Maybe the white-paper seeks to take account of anxieties regarding certain treatments, particularly E.C.T. and psychosurgery; if so, it is probably off-target. Two
say-so of an untrained police officer and it is doubtful that any politician, psychiatrist, nurse, lawyer, or tradeunionist would be quite so sanguine about this provision
reviews of E.C.T.11,12 conclude that the risk of serious adverse effects is very low, while an exhaustive assessment of psychosurgical interventions13,14 indicates that unwanted sequelae would be greatly reduced if the operations were confined to a few specialised centres adhering to agreed standards of preoperative and postoperative assessment. How could such developments be accelerated by mental-health legislation? The existing Act is ambiguous about treatment of patients in compulsory detention. This is particularly so in section 25, which provides for the detention of a patient for "observation with or without medical treatment" but does not explicitly allow treatment to be imposed without consent. It is now suggested that this section should explicitly provide for short-term assessment and treatment of all forms of mental disorder. The whitepaper expresses the hope that in modern psychiatric practice, compulsory detention need seldom last longer than 28 days, most patients either transferring to informal admission or being discharged during that period. But the most serious objection to section 25-the inability of a detained patient to appeal-is not met by the new proposals. Instead, there is a vague suggestion that some limited form of review (that is, less than the full paraphernalia of a mental-health review tribunal) might prove possible. Yet the World Psychiatric Association’s Declaration of Hawaii,’s a statement of psychiatric ethics provoked in part by the controversy over the abuse of Soviet psychiatry and in particular the compulsory detention of political dissidents, insists that "Whenever there is compulsory treatment or detention there must be an independent and neutral body of appeal for regular enquiry into these cases", and that every detained patient is entitled to know of the existence of such an appeal body and of his right to appeal to it, personally or through a representative, "without interference by the hospital staff or by anyone else". The suggested scheme whereby section-25 patients would be allowed to appeal to a body composed of members of the hospital staff or management would hardly suffice. How is it that the Royal College of Psychiatrists, rightly vigilant concerning the potential and actual abuse of psychiatric practice in other parts of the world, has raised no whimper against this section of the Act? There are other anomalies relating to compulsory detention in the whitepaper. Why, for example, should a person, removed under section 136 from a public place by a policeman who) suspects that he is suffering from mental disorder and is in need of care and control, have to wait up to 72 hourss so that he can be examined by a doctor and a social worker. Even with today’s uncertain transport, it is hard1 to see why any psychiatrist should need three days to get to the Shetlands, let alone Bodmin or Bootle. Three days seems a long time to spend in a mental hospital on the
were
recent
.
-
-
_
11.
Royal College of Psychiatrists’ Memorandum sive Therapy, Br J. Psychiat 1977, 131, 261
on
the Use of Electroconvul-
12 Fink, M. Compreh Psychiat 1978, 19,1. 13. Valenstein, E. S. in Psychosurgery, U.S. National Commission for the Pro0tection of Human Subjects of Biomedical and Behavioural Research; h; appendix 1-1-1-143. U S DHEW Publ. no. (05) 77-0002 Washington
D.C., 1977 14. Lancet, 1979, i, 367 15 Declaration of Hawaii
London, 1977
on
Psychiatric
Ethics, World
Psychiatric Association,
he to be detained for such a period on grounds which turned out to be inappropriate though legal. The white-paper struggles to maintain a balance between the need to protect staff, particularly nursing staff, against unnecessary legal actions undertaken by patients under their care, and the need to ensure that patients themselves are protected against staff abuse. It cannot be said to have succeeded. The present section 141 provides that civil or criminal proceedings against a person acting or purporting to act in pursuance of the Mental Health Act can be brought only with the leave of the High Court. The white-paper proposes that criminal actions should be removed from the scope of section 141 and that patients should be permitted to proceed if there are "reasonable" rather than the at present "substantial" grounds for the contention that the defendant acted in bad faith or without reasonable care. MIND points out that psychiatric patients seldom resort to legal action. The Confederation of Health Service Employees sharply disagrees with the white-paper proposals.16 Already we see staff organisations refusing to cope with patients likely to cause serious nursing and other management problems, and this increasing tendency is having serious implications for the courts, the prisons, and the community.
The timorous and half-hearted quality of the white-paper is never better illustrated than in the discussion of the mentally abnormal offender. Most of the major problems in this area are left.untouched. The Home Secretary is left with his immense and unchallengeable powers of restriction on the discharge of certain patients virtually intact-a clear example of Department of Health impotence in the face of Home Office intransigence. The courts will still find themselves frustrated by hospitals unwilling to receive seriously disturbed offenders, and the prisons will still be the subject of media vilification over the use of psychiatric drugs to control mentally ill offenders. It is the old familiar story of protracted discussions followed by compromise and vacillation. Inevitably, there is reference to the much-vaunted "special units" recommended by the Butler Committee, despite the growing realisation that such units, even were they to be built on the scale originally envisaged, would have little impact on the problem of offender patients who require levels of security not provided by open-door hospitals. At times, indeed, the whitepaper borders on fantasy, as when it discusses the suggestion that social workers might play a statutory role in the provision of care and control of persons made subject to proposed community-care orders. The existing dearth of properly trained social workers is totally ignored; and there is scant mention of the need for special skills in this sphere, though in one American survey only 10% of psychiatrists judged their knowledge of commitment laws 16. The
Management of Violent or Potentially Service Employees, 1977
of Health
Violent Patients Confederation
761
adequate.17 British psychiatrists may of* ject-based. That is, the student is exposed to teaching in a series of different disciplines which by the end of the be better informed. course, it is hoped, will have given the young doctor the This white-paper illustrates the strengths and basic information and skills he or she needs before weaknesses of the classic British compromise. The embarking upon a medical career. In many medical central question of the definition of mental illness schools attempts have been made at breaking down the is completely dodged, despite the evident dangers of barriers between subjects by "integrated" teachingleaving this issue open to different cultural and where, for example, the cardiovascular system is studied social interpretations and the tendency of psychiin all its aspects=but these methods have not led to any atrists to diagnose psychiatric disease where it is fundamental change of attitude among teachers. A absent.18,19 The idea that mental illness is a medical group from the University of Illinois,’ on behalf of the in entrenched British and is World Health Organisation, have now prepared an inlegal responsibility troduction to "competency-based" teaching. Essentially, medical thought, and so it should be. But this on the a they are discussing how to construct a medical training professionals places special responsibility starting with the question: "What do we need to teach criteria commitment and to for to tighten the in order to produce competent doctors?" The question is widen the scope for peer review, multidisciplinary a simple one to ask but the amount of published work supervision, and public accountability. It is not on the subject shows that it is by no means simple to enough for psychiatrists to point to their high stananswer. To define what knowledge and skills are dards and codes of practice, for they are rarely in required to carry out, say, a tracheostomy, is one thing; but trying to split up the whole of a doctor’s work into question. What disturbs observers is the danger that psychiatrists, nurses, and social workers may a series of competencies is simply another form of fragbecome the agents of thought control and political mentation, and anyway much that a doctor needs to know cannot be set out in such a precise manner, as the indoctrination through an insidious, even unwitIllinois group are well aware. Many of the principles of ting process. The present opportunity to allay such competency-based medical education would meet little misgivings by constructing a piece of mental-health from any quarter: defining what the students legislation which permits the widest possible indi- objection need to learn, deciding how this objective should be vidual freedom while protecting the seriously achieved, and then measuring the efficacy of the instrucpsychotic from harming themselves or others, if tion. The difficulty comes in determining the content of seized courageously, could represent a new point of the courses, and on the relative importance of the different topics. What is more, the needs of a country departure. As it stands, the white-paper, for all its where there is 1 doctor per 29 000 population (and 1 good intentions, has all the appearance of tinkernurse for 43 000) with about$1 per head to spend on with the is a when what is ing engine required health services will be quite different from those where overhaul of all the thorough parts. to
be
course
HOW TO TRAIN DOCTORS
STUDENTS ask:
"Why do we have to learn so much anaAnstomy-physiology-biochemistry-cell biology-&c?" wer : "Because they are there." "They" in these cases is not so much the subject matter as the large university departments which do the teaching. If courses are modified drastically, as most contributors to the medical education debate suggest that they should be, then certain .departments will be threatened because a change of emphasis in undergraduate teaching means a change of importance for these departments, and no one wants to relinquish resources. Although the responsibilities of medical schools include the training of doctors, only an optimist would suppose that medical teachers ever sit down together and ask themselves: "what must we teach these young men and women to make them into good doctors?" Thus it is still possible in Britain for the anatomy of the nervous system to be taught separately from the physiology of the nervous system, and for a medical school to devote one month to perinatology and no time at all to geriatrics. Prolonged and acrimonious negotiation has sometimes been needed to secure a place for behavioural-science teaching in the preclinical curriculum. Medical education in 17 Peszke. M
most
parts of the world is sub-
there is 1 doctor per 960 persons (and 1 nurse per 200) and$100 per head to spend. Throughout their report the Illinois team point to the conservatism that hinders progress. Distinction in research brings the greatest prestige and opportunities for travel abroad and larger research grants, while "creative work in medical education is the function least likely to bring academic recognition or reward." In highly developed Western societies medical research and improved health services are unlikely to have any noticeable impact on the quality of life of the general population. The same is certainly not true for the rest of the world, yet many of the medical teachers in the developing countries have themselves been taught in high-technology Western medical centres; and many developing countries have fallen for the expensive Western pattern teaching hospital in the capital which absorbs a large part of the nation’s health budget and tends to perpetuate hospital-based specialist teaching. The Illinois group are suggesting changes which, for once, do not primarily involve cash, and they recognise that "the greatest impediments are found in the heart, not in the purse." As they see it, the only hope of improving medical education and making it more relevant to the different things doctors do in different parts of the world is for the status of medical teachers to be enhanced in relation to that of researchers; for the pressure for change from outside the medical profession to
A., Wintrob,R.M. Am. J.Psychiat.1974, 131, 36.
Rosenhan, D.L. Science, 1973, 179, 250. 19 Kittrie, N.N.The Right to be Different: Deviance and Enforced
18
Baltimore, 1972.
W. C., Miller, G. E , Sajid, A. W, Telder, T. V. CompetencyBased Curriculum Development in Medical Education An Introduction PublicHealthPapers no. 68 .World Health Organisation, Geneva, 1978.
1. McGaghie,
Therapy.
THE LANCET Law and Mental Disorder MENTAL-HEALTH legislation is as subject to fashions and cycles as any other area of law. Most of the commitment laws stressing judicial or police involvement were enacted in the middle of the 19th
century. Emphasis on formal structures and court review continued during the asylum era, in the course of which the mentally ill and the retarded were segregated and generally lost their legal capacity and their civil rights. Not until the middle of this century did alterations in treatment methods and public attitudes towards the mentally ill have an effect on the Law. After 1950, mental-health legislation in most developed countries was substantially revised. Yet the British Mental Health Act of 1959 has been much criticised. Since 1975 proposals for change have come from the Royal College of Psychiatrists,2 the National Association for Mental Health,3,4 the British Association of Social Workers,5 and the Butler Committee;6 a
conference of interested parties followed the appearance of a consultative document;’ and now we have the long-awaited white-paper.8 The present cycle is characterised by four main aspirations. The first, and a principle enshrined in the report9 which inspired the 1959 Act, is that people with mental disorder should as far as possible be treated in the same way as those with physical illness. Secondly, treatment whenever possible should be voluntary, involuntary measures being reserved for emergencies and the last resort. Thirdly, special legal "labelling" of the mentally retarded should be abolished and these people should have the same access as other citizens education and rehabilitation. to appropriate Fourthly, the mental-health programmes should be integrated into the general health and social services, particularly at their point of delivery in the hospitals and the community. So, after all the discussions, proposals and counter proposals, how do the Government’s recommendations stand up? The growth of psychiatric units within district general and teaching hospitals, the increasing interest shown in the provi-
one-day
1
Curran,
W. J.,
Harding,
T. W. The Law and Mental Health:
Harmonising
Obiectives.World Health Organisation, Geneva, 1978. 2 Royal
of
Psychiatrists’ Working Party. Br. J.Psychiat. notes and news suppl, October, 1974. 3 Gostin, L O. A Human Condition. The Mental Health Act from 1959 to 1975 London, 1975. 4 Gostin, L. O. A Human Condition. The Law Relating to Mentally Abnormal Offenders. London, 1977.
College
5 Mental Health Crisis Services—A New Philosophy. British Association of Social Workers, Birmingham, 1977. 6 Report of the Committee on Mentally Abnormal Offenders. Cmnd 6244. H M. Stationery Office, 1975. 7 A Review of the Mental Health Act 1959. H.M.Stationery Office, 1976. 8 Review of the Mental Health Act 1959. Cmnd 7320. H.M. Stationery Office, 1978 9 Report of the Royal Commission on the Law Relating to Mental Illness and Mental Deficiency.Cmnd 169. H.M. Stationery Office, 1957.
sion of effective psychiatric treatment within the area of primary health care, and the greater awareness of psychological and social factors in the genesis of ill-health, physical as well as mental, are all pointers towards a greater integration of the psychiatric and medical services. Such features which still discriminate against the mentally ill and
retarded-e.g., inadequate facilities, shoddy food, and poor staffing-are more likely to be corrected by a diversion of Health Service funds than by legislation. Much pride is rightly taken in the fact that over 90% of admissions to psychiatric hospitals and units in Britain are voluntary and the white-paper endorses the principle that mentally ill people should as far as possible be on equal footing with physically ill people. So it is odd to find the document proposing that informally admitted psychiatric patients should be given a statement of their legal rights on admission to hospital. Is it suggested that all patients admitted to hospital in Britain, the physically ill as well as psychiatric patients, should be given such a statement and if not why not? After all, a patient with chronic renal disease often has as good reason to know his civil rights as a patient with phobic anxiety. Similar contradictions surround the discussion of the concept of informed consent. The National Association for Mental Health muddied the waters by asserting that a sizeable number of patients admitted informally are acting under coercion by relatives and doctors.10 Such allegations have been contested vigorously by psychiatrists who maintain that often the only person competent to decide whether a patient is giving informed consent is the doctor in charge of the patient: it is for the doctor, they say, to make the clinical decisions and obtain consent to admission and treatment while it is for the patient, or whoever is acting in his interest, to decide whether to accept admission and the treatments proposed. There seems little sense in a distinction in Law between the consent uttered by an informal psychiatric patient and that given by a patient faced with medical, surgical, or dental treatment. In the event of an informal patient being judged unable to give proper consent, then the same arrangements should govern the decision about psychiatric treatment as would apply to any other similarly incapacitated non-psychiatric patient. Whether the decision is to be made by a multidisciplinary panel or by peer medical review, the same procedure should surely apply to a surgical operation as to electroconvulsive therapy. Provisions for informal consent need form no part of any mental health act. There is further confusion over "hazardous" treatments. Influenced no doubt by MIND’s submissions on the subject, the white-paper defines these treatments as those "where the risk of adverse reaction or the severity of such reaction would be disproportionate to the degree of benefit the treatment is likely to confer or the prospect of success". It is difficult to see how any doctor could employ such treatments without running a serious risk of legal action, so why does the white-paper interest itself so closely in the control and regulation, whether medical or multidisciplinary, of such unethical practice. 10. Gostin, L. O A Human Condition The Mental Health Act from 1959 to 1975 London, 1975.
760
Maybe the white-paper seeks to take account of anxieties regarding certain treatments, particularly E.C.T. and psychosurgery; if so, it is probably off-target. Two
say-so of an untrained police officer and it is doubtful that any politician, psychiatrist, nurse, lawyer, or tradeunionist would be quite so sanguine about this provision
reviews of E.C.T.11,12 conclude that the risk of serious adverse effects is very low, while an exhaustive assessment of psychosurgical interventions13,14 indicates that unwanted sequelae would be greatly reduced if the operations were confined to a few specialised centres adhering to agreed standards of preoperative and postoperative assessment. How could such developments be accelerated by mental-health legislation? The existing Act is ambiguous about treatment of patients in compulsory detention. This is particularly so in section 25, which provides for the detention of a patient for "observation with or without medical treatment" but does not explicitly allow treatment to be imposed without consent. It is now suggested that this section should explicitly provide for short-term assessment and treatment of all forms of mental disorder. The whitepaper expresses the hope that in modern psychiatric practice, compulsory detention need seldom last longer than 28 days, most patients either transferring to informal admission or being discharged during that period. But the most serious objection to section 25-the inability of a detained patient to appeal-is not met by the new proposals. Instead, there is a vague suggestion that some limited form of review (that is, less than the full paraphernalia of a mental-health review tribunal) might prove possible. Yet the World Psychiatric Association’s Declaration of Hawaii,’s a statement of psychiatric ethics provoked in part by the controversy over the abuse of Soviet psychiatry and in particular the compulsory detention of political dissidents, insists that "Whenever there is compulsory treatment or detention there must be an independent and neutral body of appeal for regular enquiry into these cases", and that every detained patient is entitled to know of the existence of such an appeal body and of his right to appeal to it, personally or through a representative, "without interference by the hospital staff or by anyone else". The suggested scheme whereby section-25 patients would be allowed to appeal to a body composed of members of the hospital staff or management would hardly suffice. How is it that the Royal College of Psychiatrists, rightly vigilant concerning the potential and actual abuse of psychiatric practice in other parts of the world, has raised no whimper against this section of the Act? There are other anomalies relating to compulsory detention in the whitepaper. Why, for example, should a person, removed under section 136 from a public place by a policeman who) suspects that he is suffering from mental disorder and is in need of care and control, have to wait up to 72 hourss so that he can be examined by a doctor and a social worker. Even with today’s uncertain transport, it is hard1 to see why any psychiatrist should need three days to get to the Shetlands, let alone Bodmin or Bootle. Three days seems a long time to spend in a mental hospital on the
were
recent
.
-
-
_
11.
Royal College of Psychiatrists’ Memorandum sive Therapy, Br J. Psychiat 1977, 131, 261
on
the Use of Electroconvul-
12 Fink, M. Compreh Psychiat 1978, 19,1. 13. Valenstein, E. S. in Psychosurgery, U.S. National Commission for the Pro0tection of Human Subjects of Biomedical and Behavioural Research; h; appendix 1-1-1-143. U S DHEW Publ. no. (05) 77-0002 Washington
D.C., 1977 14. Lancet, 1979, i, 367 15 Declaration of Hawaii
London, 1977
on
Psychiatric
Ethics, World
Psychiatric Association,
he to be detained for such a period on grounds which turned out to be inappropriate though legal. The white-paper struggles to maintain a balance between the need to protect staff, particularly nursing staff, against unnecessary legal actions undertaken by patients under their care, and the need to ensure that patients themselves are protected against staff abuse. It cannot be said to have succeeded. The present section 141 provides that civil or criminal proceedings against a person acting or purporting to act in pursuance of the Mental Health Act can be brought only with the leave of the High Court. The white-paper proposes that criminal actions should be removed from the scope of section 141 and that patients should be permitted to proceed if there are "reasonable" rather than the at present "substantial" grounds for the contention that the defendant acted in bad faith or without reasonable care. MIND points out that psychiatric patients seldom resort to legal action. The Confederation of Health Service Employees sharply disagrees with the white-paper proposals.16 Already we see staff organisations refusing to cope with patients likely to cause serious nursing and other management problems, and this increasing tendency is having serious implications for the courts, the prisons, and the community.
The timorous and half-hearted quality of the white-paper is never better illustrated than in the discussion of the mentally abnormal offender. Most of the major problems in this area are left.untouched. The Home Secretary is left with his immense and unchallengeable powers of restriction on the discharge of certain patients virtually intact-a clear example of Department of Health impotence in the face of Home Office intransigence. The courts will still find themselves frustrated by hospitals unwilling to receive seriously disturbed offenders, and the prisons will still be the subject of media vilification over the use of psychiatric drugs to control mentally ill offenders. It is the old familiar story of protracted discussions followed by compromise and vacillation. Inevitably, there is reference to the much-vaunted "special units" recommended by the Butler Committee, despite the growing realisation that such units, even were they to be built on the scale originally envisaged, would have little impact on the problem of offender patients who require levels of security not provided by open-door hospitals. At times, indeed, the whitepaper borders on fantasy, as when it discusses the suggestion that social workers might play a statutory role in the provision of care and control of persons made subject to proposed community-care orders. The existing dearth of properly trained social workers is totally ignored; and there is scant mention of the need for special skills in this sphere, though in one American survey only 10% of psychiatrists judged their knowledge of commitment laws 16. The
Management of Violent or Potentially Service Employees, 1977
of Health
Violent Patients Confederation
761
adequate.17 British psychiatrists may of* ject-based. That is, the student is exposed to teaching in a series of different disciplines which by the end of the be better informed. course, it is hoped, will have given the young doctor the This white-paper illustrates the strengths and basic information and skills he or she needs before weaknesses of the classic British compromise. The embarking upon a medical career. In many medical central question of the definition of mental illness schools attempts have been made at breaking down the is completely dodged, despite the evident dangers of barriers between subjects by "integrated" teachingleaving this issue open to different cultural and where, for example, the cardiovascular system is studied social interpretations and the tendency of psychiin all its aspects=but these methods have not led to any atrists to diagnose psychiatric disease where it is fundamental change of attitude among teachers. A absent.18,19 The idea that mental illness is a medical group from the University of Illinois,’ on behalf of the in entrenched British and is World Health Organisation, have now prepared an inlegal responsibility troduction to "competency-based" teaching. Essentially, medical thought, and so it should be. But this on the a they are discussing how to construct a medical training professionals places special responsibility starting with the question: "What do we need to teach criteria commitment and to for to tighten the in order to produce competent doctors?" The question is widen the scope for peer review, multidisciplinary a simple one to ask but the amount of published work supervision, and public accountability. It is not on the subject shows that it is by no means simple to enough for psychiatrists to point to their high stananswer. To define what knowledge and skills are dards and codes of practice, for they are rarely in required to carry out, say, a tracheostomy, is one thing; but trying to split up the whole of a doctor’s work into question. What disturbs observers is the danger that psychiatrists, nurses, and social workers may a series of competencies is simply another form of fragbecome the agents of thought control and political mentation, and anyway much that a doctor needs to know cannot be set out in such a precise manner, as the indoctrination through an insidious, even unwitIllinois group are well aware. Many of the principles of ting process. The present opportunity to allay such competency-based medical education would meet little misgivings by constructing a piece of mental-health from any quarter: defining what the students legislation which permits the widest possible indi- objection need to learn, deciding how this objective should be vidual freedom while protecting the seriously achieved, and then measuring the efficacy of the instrucpsychotic from harming themselves or others, if tion. The difficulty comes in determining the content of seized courageously, could represent a new point of the courses, and on the relative importance of the different topics. What is more, the needs of a country departure. As it stands, the white-paper, for all its where there is 1 doctor per 29 000 population (and 1 good intentions, has all the appearance of tinkernurse for 43 000) with about$1 per head to spend on with the is a when what is ing engine required health services will be quite different from those where overhaul of all the thorough parts. to
be
course
HOW TO TRAIN DOCTORS
STUDENTS ask:
"Why do we have to learn so much anaAnstomy-physiology-biochemistry-cell biology-&c?" wer : "Because they are there." "They" in these cases is not so much the subject matter as the large university departments which do the teaching. If courses are modified drastically, as most contributors to the medical education debate suggest that they should be, then certain .departments will be threatened because a change of emphasis in undergraduate teaching means a change of importance for these departments, and no one wants to relinquish resources. Although the responsibilities of medical schools include the training of doctors, only an optimist would suppose that medical teachers ever sit down together and ask themselves: "what must we teach these young men and women to make them into good doctors?" Thus it is still possible in Britain for the anatomy of the nervous system to be taught separately from the physiology of the nervous system, and for a medical school to devote one month to perinatology and no time at all to geriatrics. Prolonged and acrimonious negotiation has sometimes been needed to secure a place for behavioural-science teaching in the preclinical curriculum. Medical education in 17 Peszke. M
most
parts of the world is sub-
there is 1 doctor per 960 persons (and 1 nurse per 200) and$100 per head to spend. Throughout their report the Illinois team point to the conservatism that hinders progress. Distinction in research brings the greatest prestige and opportunities for travel abroad and larger research grants, while "creative work in medical education is the function least likely to bring academic recognition or reward." In highly developed Western societies medical research and improved health services are unlikely to have any noticeable impact on the quality of life of the general population. The same is certainly not true for the rest of the world, yet many of the medical teachers in the developing countries have themselves been taught in high-technology Western medical centres; and many developing countries have fallen for the expensive Western pattern teaching hospital in the capital which absorbs a large part of the nation’s health budget and tends to perpetuate hospital-based specialist teaching. The Illinois group are suggesting changes which, for once, do not primarily involve cash, and they recognise that "the greatest impediments are found in the heart, not in the purse." As they see it, the only hope of improving medical education and making it more relevant to the different things doctors do in different parts of the world is for the status of medical teachers to be enhanced in relation to that of researchers; for the pressure for change from outside the medical profession to
A., Wintrob,R.M. Am. J.Psychiat.1974, 131, 36.
Rosenhan, D.L. Science, 1973, 179, 250. 19 Kittrie, N.N.The Right to be Different: Deviance and Enforced
18
Baltimore, 1972.
W. C., Miller, G. E , Sajid, A. W, Telder, T. V. CompetencyBased Curriculum Development in Medical Education An Introduction PublicHealthPapers no. 68 .World Health Organisation, Geneva, 1978.
1. McGaghie,
Therapy.
