Is supervised community treatment ethically justifiable?

Abstract

Ethical viewpoints for and against the use of supervised community treatment (SCT), also known as outpatient commitment and community treatment orders, are examined. The perspectives of writers on civil liberties are considered. This paper argues that while civil liberties are an important concern SCT is ethically justifiable in the circumscribed population of 'revolving door' patients it applies to. This is on the grounds that it enables individuals to actualise their positive liberty. The issue of insight into mental illness is also considered and it is concluded that a further argument in favour of SCT comes from evidence that insight relates to neurobiological deficits. Limits to the ethical justifiability of SCT are considered with reference to individuals with substance dependency. The paper concludes that SCT is ethically permissible only in those with severe mental illness who have a history of losing capacity to consent to treatment and/or admission.

The use of community treatment orders in competent patients is not justified

“…The clash of forced treatment against competent refusal created by these traditional CTOs provides a basis for strong ethical arguments against them based on the grounds of both discrimination and human rights violations. 2,3 Human rights arguments against CTOs have come to increasing prominence in recent years since the advent of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) that most nations have now either signed or ratified. The CRPD was constructed around the social model of disability, and places much of the burden of 'disability' in the context of the community's failure to make appropriate accommodation for impairment.…”

Little evidence for community treatment orders – a battle fought with heavy weapons

“… Coercion with treatment for mental disorder in the patients' best interest is justified on ethical grounds and is a feature of the legislative arrangements in many jurisdictions. 6 There is no clear logical reason why this right or duty to appropriate treatment should be available in the restrictive hospital setting, but not in the community. For this purpose, it can be necessary to force non-adherent patients to accept necessary treatment and medication. 4 There is sufficient professional experience of patients improving under a CTO to justify this type of coercion.…”

Community treatment orders: exploring the paradox of personalisation under compulsion

“…However, it is argued that CTOs are justifiable ethically on the grounds of helping ‘revolving door patients’ to stay out of hospital and to progress to recovery with the help of the stabilising effects of medication (Torrey & Zdanowicz , Cornwell & Deeney , Mullen et al . , Dale , Gibbs ). CTOs can also be justified on the basis of fulfilling the ‘least restrictive’ care option.…”

“…Concerns have been raised about the political drivers for community treatment orders (CTOs) and whether these relate to cost saving through further de-institutionalisation (Galappathie 2008). However, it is argued that CTOs are justifiable ethically on the grounds of helping 'revolving door patients' to stay out of hospital and to progress to recovery with the help of the stabilising effects of medication (Torrey & Zdanowicz 2001, Cornwell & Deeney 2003, Mullen et al 2006, Dale 2010, Gibbs 2010. CTOs can also be justified on the basis of fulfilling the 'least restrictive' care option.…”