J Law Med Ethics 2019 Mar;47(1):126-133
Giles Newton-Howes, B.A., B.Sc., M.B.Ch.B., M.R.C.Psych., F.R.A.N.Z.C.P., PostDip.C.B.T., Ph.D., is an associate professor in the department of psychological medicine, University of Otago, Wellington. He is seconded to Te-Upoko-me-Te-Karuo-Te-Ika, the public health service that delivers mental health care to the lower part of the North Island of New Zealand, where he works as a consultant psychiatrist.
Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders (CTOs) are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities (CRPD) and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate.