John Stuart Mill and the

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John Stuart Mill and the
Compulsory Treatment of the
Mentally Ill
Vaughan Bell vaughan_at_backspace.org
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Premise

• Mill exempts certain people from his Liberty
  Principle.
• e.g. those with mental illness.
• The diagnosis of certain forms of mental illness
  relies on incoherent or weak diagnostic criteria.
• Considering this, I will examine whether
  including persons with mental illness in the
  Liberty Principle makes for a more consistent
  approach.

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Introduction

• JSM, the Liberty Principle, and the exception of
  the mental illness.
• Developments in psychiatry and their implication
  for Mills exception
• Delusions.
• The continuum model of psychosis.
• Insight and health decisions.
• Conclusions

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John Stuart Mill

• 1806-1873
• Suffered his own mental crisis at the age of
  19.
• Probably a severe depressive episode.
• Wrote extensively on many topics, although I will
  focus on the arguments in On Liberty.

• Frequently quoted by anti-psychiatry movement,
  for example Thomas Szasz (1971), who argues that
  any compulsory treatment is incompatible with a
  free society.

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The Liberty Principle

• John Stuart Mill states a very simple principle
  of when a society may intervene into a persons
  affairs
• That the only purpose for which power can be
  rightfully exercised over any member of a
  civilised community, against his will, is to
  prevent harm from others. His own good, either
  physical or moral, is not a sufficient warrant

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Exceptions

• However, he makes exceptions to his principle for
  those with mental illness
• ...this doctrine is meant to apply only to human
  beings in the maturity of their faculties
• and also
• unless he is a child, or delirious, or in some
  state of excitement or absorption incompatible
  with the full use of the reflecting faculty
• I am going to call people for whom the Liberty
  Principle is not intended to apply LP Exempt.

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Internal Ambiguities

• Currently, treatment of severe mental illness may
  involve compulsory treatment.
• At first this seems compatible with Mill. Mental
  illness makes you LP exempt, so detention is not
  a violation to your right to liberty.
• However, there are further ambiguities present.
• e.g. personal responsibility for mental health
• Each is the proper guardian of his own health,
  whether bodily, or mental or spiritual. Mankind
  are greater gainers by suffering each other to
  live as seems good to themselves, than by
  compelling each to live as seems good to the
  rest.

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Internal Ambiguities

• And when applied to compulsory detention, serious
  question begging (cart before horse)
• Those who are still in a state to require being
  taken care of by others, must be protected
  against their own actions as well as against
  external injury.

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General Rule

• Despite the internal ambiguities, we can extract
  a general rule from On Liberty.
• We can surmise that for Mill, forceful coercion
  may only be used
• To prevent harm to other members of society.
• When a person is LP exempt.

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Influence of Psychiatry
Developments in psychiatry influence who is, and
who isnt LP exempt Application of the Liberty
Principle relies on individuals having
maturity and full use of faculties, an
exception to which relies on psychiatric
assessment, which relies on current
understanding of psychopathology.
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Delusions

• Psychiatry makes a distinction between normal
  beliefs and those that can be diagnosed as
  delusional.
• The DSM-IV describes a delusion thus
• A false belief based on incorrect inference
  about external reality that is firmly sustained
  despite what almost everybody else believes and
  despite what constitutes incontrovertible and
  obvious proof or evidence to the contrary.
• According to the Liberty Principle, we have no
  right to suppress the expression of normal
  beliefs.
• But a diagnosis of a belief as delusional may
  make you, or the belief, LP exempt.

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Delusions Counter examples

• However, the DSM criteria are somewhat shaky
• firmly sustained
• Myin-Germeys (2001) found that intensity of
  delusions may change during the day.
• incorrect inference about external reality
• Spitzer (1990) has noted that this statement may
  be
• not applicable (Satan listens to my thoughts).
• not provable (I am being bugged by the CIA)
• not true ! (e.g. delusional jealousy)

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Delusions Counter examples

• despite what constitutes incontrovertible and
  obvious proof or evidence to the contrary
• Thomas Kuhn (1962) demonstrated that scientists
  may continue to hold strong beliefs despite
  overwhelming contradictory evidence.
• As can be seen, the psychiatric criteria which
  would render a belief LP exempt is incoherent.

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Justification for Detention

• Since the normal / pathological distinction is
  not adequate, when might detention be justified ?
• Clear cut
• Mill makes clear that all thought is
  self-regarding, so thought (or belief) itself is
  no basis for detention.
• If a belief is acted on in a way that harms
  others, compulsory detention can be justified.
• Not so clear cut
• Mill argues that expression of belief cannot be
  be treated as self-regarding if it has at least
  a probable connexion to a harmful act.

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Connection to Risk

• In psychiatry, this relies on a forensic
  assessment of risk.
• If a risk assessment is 95 accurate and 100 out
  of 10,000 (0.01) will cause a harmful act
• 95 harmful people will be detained
• 5 will commit their act.
• 495 harmless people will be detained.
• On utilitarian LP grounds, the right to be free
  from unjust detention would seem to outweigh the
  good done by protecting the public.
• In this case Mills principle is not consistent.

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Expressing Beliefs

• Beliefs labelled as delusions are often intensely
  held, pre-occupying the believer, sometimes
  leading to unusual or bizarre behaviour.
• Mill considers the idea that free expression
  should require fair and temperate discussion, but
  rejects it as too restrictive.
• But, he does say that the liberty of an
  individual must be thus far limited must not
  make himself a nuisance to other people.
• In this case, a delusion is treated like any
  other belief, where expression, not content, is
  used to assess LP exempt status.

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Delusions and Mill

• If we are to take the definition of a delusion
  (and hence LP exempt status) as incoherent...
• Justified detention in the case of a person
  presenting with a delusion, according to Mill
  depends on
• A dangerous act.
• An expression of a belief with a probable
  connection to a dangerous act.
• The expression of a belief which becomes a
  nuisance to others.
• This seems to be no less ambiguous and value
  laden than the psychiatric route.

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Psychosis

• Psychosis is a mental state in which the
  perception of reality is distorted, common
  phenomena are
• Hallucinations (e.g. voices, images, smells,
  tactile sensations)
• Delusions (e.g. persecutory, grandiose,
  religious, erotomanic)
• Formal thought disorder (e.g. flight of ideas,
  derailment, clanging)
• In psychiatry, the traditional view is that there
  is a qualitative difference between a psychotic
  and non-psychotic state.

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Continuum Model

• More recently it has been shown that such
  experiences are common throughout the population
  and the difference may be a quantitative one.
• 20.9 GP patients reported one or more psychotic
  symptoms (Olfson et al, 2002)
• 38.7 reported hallucinatory experiences (Ohayon,
  2000)
• Delusions questionnaire 10 of general
  population scored above the mean of the deluded
  inpatient group (Peters et al, 1999)

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Religion and the Continuum

• Peters et al (1999) showed that members of New
  Religious Movements may endorse almost as many
  anomalous experiences and beliefs as clinically
  deluded inpatients.
• However, there is no suggestion that people in
  these groups are more mentally ill then the
  general population.
• So, in this case, the criteria which would render
  a person LP exempt are inconsistent.

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Individuality and Psychosis

• It seems that people who have more psychotic
  experience are simply statistically anomalous and
  hence more likely to stand out as individuals.
• Indeed, Szasz (1962) makes a similar argument and
  argues that mental illness is a construct to
  control the anomalous.
• Mill himself specifically noted the abuse of
  psychiatry to oppress those who do not conform.

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Mill on Abuse of Psychiatry
To indulge somewhat, I repeat for whoever allow
themselves much of that indulgence of
non-conformity, incur the risk of something
worse than disparaging speeches they are in
peril of a commission de lunatico
All of the minute details of his daily life are
pried into, and whatever is found is laid before
the jury as evidence of insanity
In former days, when it was proposed to burn
atheists, charitable people used to suggest
putting them in a madhouse instead it would be
nothing surprising now-a-days were we to see this
done, and the doers applauding themselves,
because, instead of persecuting for religion,
they had adopted so humane and Christian a mode
of treating these unfortunates
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Justification for Coercion

• With regarding to self-regarding conduct (inc.
  self injurous conduct), Mill argues society has
  no legitimate authority.
• Persons ought to use firmness and self-control
  to tame negative other-regarding impulses.
• And that coercion is only justified if a person
  cannot do so.
• In this case, Mill is more consistent than a
  psychiatric assessment of LP exempt status.
• Although, self-control requires insight

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Insight in Mental Illness

• Generally speaking, insight is a state where a
  person is aware of their mental illness and its
  consequences.
• Lack of insight is likely to make you LP exempt.
• By definition, a person has no insight that a
  belief they hold might be false or delusional.
• The difficulty comes with judging what counts as
  lack of insight, and what subject of insight is
  relevant.
• There are various formulations, e.g

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Insight in Mental Illness

• Amador and David (1998) give six components
• Failure to recognise symptoms or disease.
• Misattribution of source of symptoms.
• Failure to appreciate implausibility of
  experience of beliefs.
• Failure to derive appropriate cognitive
  representations despite recognition of pathology.
• Inappropriate emotional reactions despite
  recognition of pathology.
• Inappropriate actions despite recognition of
  pathology.

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Mental State Examination

• Notably, in the MSE, a standard examination used
  by psychiatrists, insight assessment covers the
  following
• Does the patient think they are ill ?
• Do they think they have a mental illness ?
• Do they think they need treatment ?
• If so, do they accept medical treatment ?

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Informed Decisions

• An informed decision not to accept psychiatric
  treatment does not itself indicate a lack of
  insight.
• But, a lack of insight can mean that such a
  decision is not properly informed.
• What counts as valid information ?
• Those who make the assessment are likely to
  privilege information on the illness.
• Potential patients are likely to privilege
  information on the negative effects of
  hospitalisation or medication.
• Assessment of insight also implies that the
  psychiatrist is correct in the first place !

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Insight into Current State

• Mill argues that ignorance for the danger of the
  status quo is a reason for coercion.
• If a public officer saw a person attempting to
  cross a unsafe bridge, and there were no time to
  warn him of his danger, they might seize him and
  turn him back without any real infringement of
  his liberty.
• Nevertheless, when there is not a certainty, but
  only a danger of mischief, he ought, I conceive,
  to be only warned of the danger.
• paraphrase

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Medication

• Medication presents more of a problem then simple
  prevention.
• The mortality rate for manic depression is
  higher than it is for most types of heart disease
  and many types of cancer. Yet this lethality
  often is underemphasized, a tendency that may be
  traceable to the erroneous but widespread belief
  that suicide is volitional.
• (Goodwin and Jamison, 1990)
• Mill would argue against forced medication purely
  for someones own good.
• However, it could be argued that forced
  medication returns a person to a state where they
  are better able to reason decisions.
• In effect, it is a way of informing their
  decisions.

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Mental Capacity

• But this could (and does) lead to a yo-yo effect.
• A person decides they dont want medication when
  well, and is forcibly medicated when ill.
• Neither Mill nor psychiatry provide a clear
  answer.
• Livermore et al (1968) argue that
• It is true that some mentally ill people may be
  unable to comprehend a diagnosis and in these
  instances, forced treatment may be more
  appropriate.
• Which seems to point toward the need for
  decisions to be made on mental capacity, rather
  than inferring it from a diagnosis of mental
  illness.

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Responsibility and Relapse

• Interestingly, Mill might be more inclined to
  forcibly treat someone if they had
  responsibilities to fulfill.
• if either from idleness or from any other
  avoidable cause, a man fails to perform his legal
  duties to others, as for instance to support his
  children, it is no tyranny to force him to fulfil
  that obligation
• Which seems to suggest that person who falls
  mentally ill should be required to take
  responsibility for themselves if they stop
  helpful medication.

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Conclusions

• By making those with mental illness LP exempt,
  Mill has been rather sly in avoiding a difficult
  and thorny problem.
• Mill seems to be more liberal in terms of
  criteria for compulsory treatment.
• But less on the negative consequences of relapse.
• Mill requires no fewer value judgements and
  subjective decisions to be made in the care of
  the mentally ill.
• Overall, I would suggest that his principles are
  of questionable value when compared to the
  current system.

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Conclusions

• Although, perhaps useful distinctions can be made
  between compulsory detention and compulsory
  medication.
• Something which the psychiatric services user
  movement is now focusing on (May et al, 2003).