Letters to the Editor
Re: CPA Position Statement: “The Role of Mental Health Legislation”
Dear Editor: The brief position statement prepared by Grainne Neilson for the Canadian Psychiatric Association, “The Role of Mental Health Legislation,” raises the interesting issue of civil liberty compared with personal welfare (1).
According to the statement,
the circumstances in which society may assume decision making for a person with mental illness include situations (under society’s police powers) where the person is at significant risk of self harm or of inflicting harm on others and situations (under society’s parens patriae duty) where the person is unable to adequately care for himself or herself [emphasis added] (1).
There is ample evidence to suggest that for the past 25 years or more, such legislation failed to protect those suffering from severe mental illness. This failure is rooted in focusing on individual liberty instead of attempting to assess the value of such liberty to an individual whose ability to govern him- or herself is so impaired that his or her welfare is compromised. The statement refers to “a citizen’s right to live safely in society and a person’s right to liberty and autonomy” (1). In this context, autonomy seems synonymous with liberty. However, according to the Canadian philosopher Lawrence Haworth, autonomy refers to the ability to govern oneself (2) and, as the statement records, the ability to make sound decisions, presumably pertaining to personal welfare. Haworth points out that there are degrees of autonomy. The available evidence—for example, the high proportion of individuals suffering from severe mental illness among the homeless or the increased likelihood that individuals with severe mental illness will be victims of violent crime (3)—indicates that our legislation fails to ensure that individuals suffering from severe mental illness have what Haworth refers to as minimal autonomy before they enjoy their liberty. According to Haworth’s use of the term, a person has the right to liberty but not autonomy. Autonomy depends on a mind that is functioning well enough to be sufficiently mindful of personal welfare.
We must therefore conclude that the so-called balance of our legislation favours liberty over autonomy. It certainly does not ensure that an individual with severe mental illness can live safely in society despite the fact that he or she has liberty. It is understandable, given the history in Western countries of individuals’ struggles for freedom over many centuries, that the law favours freedom. The law, however, fails to recognize that unrestricted freedom may not be advantageous to individuals who are unable to adequately care for themselves.
References
1. Neilson, G. The role of mental health legislation [position statement]. Can J Psychiatry 2005;50:Insert 1.
2. Haworth L. Autonomy: an essay in philosophical psychology and ethics. Yale University Press. New Haven (CT): 1986.
3. Teplin LA, McClelland GM, Abram KM, Weiner, DA. Crime victimization in adults with severe mental illness: comparison with the national crime victimization survey. Arch Gen Psychiatry 2005;62:911–21.
Paul Hoaken, MD, FRCPC
Bath, Ontario
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