Leading Article: On the frontiers of sickness

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VIRGINIA BOTTOMLEY, the Secretary of State for Health, seems to have been moved to review the Mental Health Act 1983 by a case that is not relevant to the change she is proposing. Ben Silcock, the schizophrenic who was mauled by a lion in London Zoo, was apparently previously denied hospital treatment, despite begging to be admitted. Yet Mrs Bottomley is calling for an 'urgent shake-up of the Act' to deal with patients who abandon treatment. This was not Mr Silcock's problem. Nor is it a large problem. Probably only a few hundred people come into the category that would be affected. The proposed change does, however, raise important principles. As described by Mrs Bottomley, it would not necessarily involve compulsory treatment outside hospital. Rather, it would enable a discharged patient who refused medication to be forcibly returned to hospital without going through the procedures now needed for compulsory committal.

There are two main objections. One is the libertarian one that compulsory treatment should be confined to the barest minimum of patients who are judged a danger to themselves or others - at present about 7 per cent of admissions to mental hospitals. Mrs Bottomley's change would increase that number and erode the principle that a discharged patient is by definition someone who is judged capable of taking decisions about his or her treatment.

The second objection is that new powers are not necessary because existing procedures for compulsory treatment are adequate. More use could be made of guardianship orders that oblige discharged patients to reside at a particular address and attend day centres or hospitals without, however, compelling them to accept treatment.

The underlying problem is the difficulty of deciding how much discretion should properly be left to a mental patient. Those who regard mental illness as primarily of chemical origin would minimise personal choice. Resistance to treatment is taken as a sign of impaired judgement, which merely reinforces the diagnosis. Those who believe that mental illness can derive from a mixture of chemical, genetic and social factors accord more validity to the patient's wishes and opinions. Clearly some patients are sufficiently divorced from reality to be poor judges of their own needs, while others may be entirely right to contest a prescription of tranquillisers and ask instead for better housing. On the shifting frontiers of mental illness it may often be difficult to decide in which category a particular sufferer belongs. Any move towards reducing the scope for personal choice should, however, be treated with suspicion.

A far greater problem is the one that is in fact relevant to Mr Silcock, namely the shamefully patchy and inadequate provision of community care encountered by those discharged from mental hospitals as a result of the Mental Health Act. The reforms scheduled for April are supposed to improve matters by placing responsibility for assessing needs firmly with the social services. The idea is good, but Mrs Bottomley has yet to persuade the public that sufficient resources will be available to make it work. The mental health charity Mind suggests giving voluntary mental patients legal rights to community care. The principle would seem to accord nicely with the Citizen's Charter.

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